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CLINICAL IMAGE
Year : 2021  |  Volume : 2  |  Issue : 1  |  Page : 64-65

Hemopneumopericardium without cardiac injury: Rare consequence of a self-inflicted transmediastinal gunshot injury


1 Department of Radiology, Division of Interventional Radiology, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Trauma Surgery, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission08-Jul-2020
Date of Decision23-Jul-2020
Date of Acceptance02-Feb-2021
Date of Web Publication25-Apr-2021

Correspondence Address:
Dr. Udit Chauhan
Room No. 13, Trauma Block, AIIMS, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_116_20

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How to cite this article:
Sharma S, Chauhan U, Ratan A, Sharma P. Hemopneumopericardium without cardiac injury: Rare consequence of a self-inflicted transmediastinal gunshot injury. J Med Evid 2021;2:64-5

How to cite this URL:
Sharma S, Chauhan U, Ratan A, Sharma P. Hemopneumopericardium without cardiac injury: Rare consequence of a self-inflicted transmediastinal gunshot injury. J Med Evid [serial online] 2021 [cited 2022 Aug 12];2:64-5. Available from: http://www.journaljme.org/text.asp?2021/2/1/64/314613

A 23-year-old male presented to our emergency department within three hours of self-inflicted gunshot injury. The primary survey being normal, contrast-enhanced computed tomography (CECT) scan of the thorax and abdomen was done which showed hyperdense blood attenuation contents (hemopericardium) [Figure 1]A and air (pneumopericardium) in the pericardial cavity with an air-fluid level [Figure 1]B-arrow. No definite intracardiac injury was seen. A large hepatic contusion (white arrow) was seen in segment IVA with thrombus (black arrowhead) in supra-hepatic inferior vena cava (AAST grade V injury) [Figure 2]A. Suspicious diaphragmatic rupture [Figure 2]B-arrow was seen which was confirmed per-operatively. Skin ulceration was seen at the site of entry (thin arrow) and exit (thick arrow) wounds [Figure 2]C. Right hemopneumothorax (white arrow) and right lung contusions (black arrow) were seen [Figure 2]D. He was taken up for emergency Clamshell Thoracotomy with pericardial exploration. Operative findings conformed to CECT findings. However, no cardiac injury was found to explain the source of hemopneumopericardium. Evacuation of hemopericardium was done and the pericardium was closed after putting number 12 suction drain. The diaphragm was repaired and the liver injury was managed conservatively. The postoperative course of the patient was unremarkable with normal haematological/biochemical investigations. He was discharged after 7 days.
Figure 1: (A) Axial contrast-enhanced computed tomography image of thorax (mediastinal window) showing blood attenuation contents in the pericardial cavity. (B) Axial contrast-enhanced computed tomography image of thoraxshowing pneumopericardium (arrow) with air blood level, part of hepatic contusion and right hemothorax. Note is made of a bullet fragment away from the trajectory in left lateral wall of chest (arrowhead)

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Figure 2: (A) Axial contrast-enhanced computed tomography image of thorax and upper abdomen showing hepatic contusion (white arrow) in left lobe of liver with multiple air foci. Associated inferior vena cava thrombosis (black arrowhead) was seen. (B) Axial computed tomography image of thorax (lung window) showing pneumothorax and lung contusions. (C) Coronal contrast-enhanced computed tomography image showing suspicious diaphragmatic rent. (D) Sagittal contrast-enhanced computed tomography image showing site of entry (thin arrow) and exit wound (thick arrow), hemothorax and hepatic contusion

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We hypothesise that hemopneumopericardium occurring in our case was secondary to a small pericardial rent which got sealed off by the time the patient was taken up for surgery. Other proposed mechanisms include cavitation effects of gunshot injury and injury to pericardial vessels.
  Teaching Point Top
Hemopericardium and pneumopericardium are important markers of penetrating injury to the heart and pericardium.[1],[2],[3] However, the concurrent occurrence of hemopneumopericardium with no operative evidence of cardiac injury is extremely rare. Causes of hemopericardium in such cases may indicate overlying pericardial vascular injury, pericardial laceration, or injury to the coronary artery or cardiac vein.[4] This case highlights the importance of imaging in accurately determining the complications of transmediastinal penetrating injuries and guiding an optimal management approach in hemodynamically stable patients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

 
  References Top

1.
Durso AM, Caban K, Munera F. Penetrating thoracic injury. Radiol Clin North Am 2015;53:675-93, vii-viii.  Back to cited text no. 1
    
2.
Gunn ML, Clark RT, Sadro CT, Linnau KF, Sandstrom CK. Current concepts in imaging evaluation of penetrating transmediastinal injury. Radiographics 2014;34:1824-41.  Back to cited text no. 2
    
3.
Restrepo CS, Gutierrez FR, Marmol-Velez JA, Ocazionez D, Martinez-Jimenez S. Imaging patients with cardiac trauma. Radiographics 2012;32:633-49.  Back to cited text no. 3
    
4.
Raptis DA, Bhalla S, Raptis CA. Computed tomographic imaging of cardiac trauma. Radiol Clin North Am 2019;57:201-12.  Back to cited text no. 4
    


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