TENSION PNEUMOMEDIASTINUM RESULTING IN OBSTRUCTIVE SHOCK IN COVID-19

SESSION TITLE: Bad bugs and Mediastinal Madness SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Pneumomediastinum is often witnessed in intensive care units secondary to mechanical ventilation, or blunt and penetrating trauma. However, it is rare for patients to develop tension pneumomediastinum. Tension pneumomediastinum within the context of Covid-19 pneumonia is even more rarely discussed. Here we discuss a patient with Covid-19 pneumonia who developed rapidly progressive tension pneumomediastinum. CASE PRESENTATION: 72-year-old male was admitted to the ICU for Covid-19 infection causing hypoxemic respiratory failure requiring mechanical ventilation. On ICU day 2 the patient developed sudden worsening of shock requiring multiple pressors. Clinical exam revealed extensive subcutaneous crepitus in the supraclavicular region extending to the neck. Chest XR showed extensive pneumomediastinum and pneumopericardium and no pneumothorax. There was concern for ongoing obstructive shock due to cardiac tamponade, cardiology was called to bedside to perform POC ultrasound. The heart could not be visualized due to subcutaneous air. CT scan showed extensive mediastinal air and subcutaneous emphysema. The significantly increasing air in the retrocardiac space and concavity of the atria were concerning for worsening tension physiology. Cardiothoracic surgery decided to place a mediastinal drain and create a pericardial window. In the hours that followed, the patient's hemodynamics improved, and his pressor requirement decreased to only low dose norepinephrine. On ICU day 3 he developed worsening severe mixed acidosis. On day 4, the patient was requiring over 100mcg per hour of norepinephrine and labs showed worsening renal and liver failure. In the afternoon of day 4, the patient experienced a cardiac arrest and expired. DISCUSSION: Most reported cases of pneumomediastinum with associated pneumopericardium are self-limited, however 38% of cases progress to create tension pneumomediastinum and life-threatening cardiac tamponade.1 There are few reports of tension pneumomediastinum complicated by pneumopericardium in patients with Covid-19,2 but there is concern that this condition occurs more frequently in critically ill patients with Covid-19.3 The management of cardiac tamponade as a result of tension pneumopericardium may include pericardiocentesis,2 placement of a pericardial window, or insertion of a mediastinal drain.3 While several reported patients who underwent these procedures survived to discharge successfully,1,3 there are also reports that suggest that the development of subcutaneous emphysema and pneumomediastinum may be indicative of worsening prognosis.3 CONCLUSIONS: The ideal management of tension pneumomediastinum in Covid-19 is not clear and prognosis of patients who develop tension pneumomediastinum is highly varied. Further study is needed to develop tools to identify pneumomediastinum with the potential to develop tension physiology and progress to obstructive shock. Reference #1: Hazariwala, V., Hadid, H., Kirsch, D. et al. Spontaneous pneumomediastinum, pneumopericardium, pneumothorax and subcutaneous emphysema in patients with COVID-19 pneumonia, a case report. J Cardiothorac Surg 15, 301 (2020). https://doi.org/10.1186/s13019-020-01308-7 Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984;37(6):511-518. doi:10.1016/s0003-4975(10)61146-0 Reference #3: Al-Azzawi M, Douedi S, Alshami A, Al-Saoudi G, Mikhail J. Spontaneous Subcutaneous Emphysema and Pneumomediastinum in COVID-19 Patients: An Indicator of Poor Prognosis? Am J Case Rep. 2020;21:e925557-1-e925557-6. doi:10.12659/AJCR.925557 DISCLOSURES: No relevant relationships by Roger Alvarez, value=Travel Removed 03/30/2022 by Roger Alvarez No relevant relationships by Roger Alvarez, value=Consulting fee Removed 03/30/2022 by Roger Alvarez no disclosure on file for Michelle Hernandez;No relevant relationships by Rose Puthumana

Tension Pneumomediastinum in COVID-19 ARDS Patient Managed with Percutaneous Ultrasound-guided Catheter Insertion: A Case Report

Introduction: Tension pneumomediastinum is a condition in which there is a trapping of air in the mediastinum with a resultant increase in the pressure causing compression of the great vessels which leads to decreased venous return and cardiovascular collapse. It is a rare and severe form of pulmonary barotrauma in ICU ventilated patients which can lead to refractory hypotension and death if not addressed at the right time. Case description: A 42-year-old man with no known comorbidities referred to our centre in view of severe COVID ARDS with refractory hypoxemia. Endotracheally intubated and put on ventilatory support. Developed shock not responding to fluid resuscitation and was started on IV vasopressor infusion. CT chest revealed tension pneumomediastinum. The patient continued to worsen clinically with hypotension and hypoxia despite low PEEP and high FiO2 ventilation. So bedside USG-guided pigtail catheter was inserted into the anterior mediastinum using a modified Seldinger technique following which there was a rapid clinical improvement. Conclusion: Tension pneumomediastinum is a rare and life-threatening cause of refractory hypotension and hypoxia in mechanically ventilated ARDS patients and bedside ultrasound-guided intervention is a feasible and quick therapeutic option. Highlights: A review of the literature showed very few case reports of tension pneumomediastinum in mechanical ventilated ARDS patients. Because ultrasound of the chest gives air artefacts and poor visualization in patients with pneumomediastinum and subcutaneous emphysema, CT-guided drainage catheters insertion is the standard of care. But in a very sick ICU patient, bedside ultrasound-guided catheter insertion could be a safe and immediate measure to save a patient's life. To our knowledge, this is the first case report of an adult ARDS patient with tension pneumomediastinum managed with bedside ultrasound-guided catheter insertion.

Surgical treatment of tension pneumomediastinum in patients with covid-19 at the field hospital: a case series.

BACKGROUND: Tension pneumomediastinum is one of the most serious complications in COVID-19 patients with respiratory distress requiring invasive mechanical ventilation. This complication can lead to rapid hemodynamic instability and death if it is not recognized in a timely manner and intervenes promptly. CASE PRESENTATION: We reported 7 COVID-19 patients with tension pneumomediastinum at a field hospital. All patients were critically ill with ARDS. These 7 patients, including 3 females and 4 males in this series, were aged between 39 and 70 years. Tension pneumomediastinum occurred on the first day of mechanical ventilation in 3 patients and later in the course of hospital stay, even 10 days after being intubated and ventilated. The tension pneumomediastinum caused hemodynamic instability and worsened respiratory mechanics with imminent cardiopulmonary collapse. In this series, we used two surgical techniques: (i) mediastinal decompression by suprasternal drainage with or without simultaneous pleural drainage in the first two cases and (ii) mediastinal drainage via suprasternal and subxiphoid incisions in 5 patients. The surgical procedures were feasible and reversed the pending cardiopulmonary collapse. Four patients had a favorable postprocedural period and were discharged from the intensive care center. Both patients undergoing suprasternal drainage died of failed/recurrent tension pneumomediastinum and nosocomial infection. Only one in five patients who underwent mediastinal drainage via suprasternal and subxiphoid incisions died of septic shock secondary to ventilator-associated pneumonia. CONCLUSION: Tension pneumomediastinum was a life-threatening complication in critically ill COVID-19 patients requiring mechanical ventilation. Surgical mediastinal decompression was the salvage procedure. The surgical technique of mediastinal drainage via suprasternal and subxiphoid incisions proved an advantage in tension relief, hemodynamic improvement and mortality reduction.