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Tension pneumomediastinum is rare but life-threatening condition. Up to date, there are less than 100 case reports in PubMed search in recent 10 years. It posed diagnostic challenges as well as immediate treatment for emergency residence.
A 53 years old gentleman was brought in to the casualty for alleged motor vehicle accident. Upon assessment, patient has low Glasgow Coma Score and was intubated for airway protection. Clinical examination revealed that patient was tachycardic with irregular pulse. There was a small bruise over the left anterior chest. However, others chest examination was unremarkable. Post intubation, patient requires high ventilator setting which raised suspicion of thoracic injury. Focused assessment of sonography was done and noted patient’s heart cannot be seen. Chest x-ray was performed shown that there was a lucent streak adjacent to the left heart border. Patient proceeded with Computed Tomography (CT) thorax and that the diagnosis of traumatic tension pneumomediastinum was confirmed.
Tension pneumomediastinum was defined as the presence of air in the mediastinum displacing mediastinal structures and compromising cardiopulmonary function. Most common causes of pneumomediastinum are mechanical ventilation, trauma, infection and lung diseases. Nowadays, there were many reported cases relating COVID -19 with pneumomediastinum.
In this case, the patient came in post trauma with severe head injury. No history was able to elicit prior to that. With regards to this patient, we were able to appreciate the lucent streak adjacent to the left heart border from the chest x-ray. However, no heart chamber seen on ultrasound. CT thorax proceeded to confirm the earlier diagnosis and have also found the causes.
The blood pressure was crashing later, and we proceed with mediastinum decompression. However, patient succumbs to death eventually. Later, the result shows that the patient was positive for COVID-19 infection.
This case highlights the importance of recognizing small sign to reach the diagnosis. Awareness is needed to reduce the possibility of underdiagnosed. Clinical suspicion should proceed with further imaging such as CT scan to help the management of patient.
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