Non-operative management of a case of pneumopericardium and vascular injury in the neck following penetrating trauma: A challenge to the trauma surgeon

INTRODUCTION

Penetrating injuries account for 6.7% of hospital admissions in India and 2.8% of deaths.¹ Treatment depends on the anatomical location, patient physiology, and injury severity. Penetrating injuries to the neck and chest are hazardous because these regions contain essential structures that can be injured in various patterns and combinations. Penetrating injury causing pneumopericardium is an uncommon but well-described entity. Most recommend operative management, either a sternotomy or a sub-xiphoid pericardial window (SPW).²

Until recently, penetrating neck injuries (PNI) to zone II were almost always managed by operative exploration. However, the management of PNIs is currently evolving with the introduction of the ‘no zone approach' and the continually improving capabilities of computed tomography (CT).³ In this report, we describe the selective non-operative management (NOM) of a patient with concurrent penetrating chest and neck injuries complicated by pneumopericardium and a delayed facial artery pseudoaneurysm, highlighting the importance of structured surveillance and timely intervention.

CASE REPORT

A 22-year-old gentleman was referred to our trauma emergency department (ED) with a history of multiple stab wounds to the neck, chest, and upper limbs after receiving primary care at a nearby hospital. The primary survey revealed respiratory distress, hypotension with tachycardia, and an extended Focused Assessment with Sonography in Trauma (eFAST) examination showing a left-sided pneumothorax. An intercostal drain (ICD) was immediately placed in the left chest. The patient was vocalizing normally, and there was no subcutaneous emphysema in the neck or chest. His vitals stabilized with an initial fluid challenge. A chest radiograph [Figure 1A] showed a pneumopericardium. A detailed secondary survey revealed multiple stab wounds in the neck and left side of the chest. All wounds were sutured at the initial treatment facility. He had three stab wounds on the left side of the neck, involving zones 2 and 3. In addition, there were multiple stab wounds in the left chest at the fifth intercostal space in the mid-axillary line and in the paraspinal area. He also sustained numerous superficial lacerations on both forearms, likely defensive wounds. None of the wounds was actively bleeding.

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Figure 1: Chest radiograph, AP (A) view, obtained in the emergency bay after insertion of an ICD on the left side, shows a left pneumothorax (black arrows), subcutaneous emphysema, and pneumopericardium (white arrows). CT thorax lung window axial (B) confirms the pneumopericardium (arrow) and left pneumothorax (star). ICD: Intercostal drain, CT: Computed tomography, AP: Anteroposterior.

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A contrast-enhanced CT scan of the torso revealed minimal residual left pneumothorax and pneumomediastinum, with pneumopericardium measuring approximately 100 ml [Figure 1B]. CT angiography (CTA) of the neck showed a left parapharyngeal space hematoma without evidence of ongoing bleeding. The airway and major neck vessels were normal. Another ICD was placed on the right side because of pneumomediastinum, and the patient was transferred to the Intensive Care Unit (ICU) for close observation.

The patient underwent NOM with continuous cardiac monitoring from admission, including serial electrocardiogram (ECG) monitoring in the ICU. Transthoracic echocardiography was performed during hospitalization, demonstrating normal cardiac function and no evidence of tamponade or pericardial effusion. The initial echocardiographic window was suboptimal, likely due to intrapericardial and mediastinal air.Enteral feeding was initiated via a nasogastric (NG) tube. A contrast swallow study performed before starting oral feeds revealed no contrast leak. The patient was doing well and accepting oral feeds. He remained hemodynamically stable. The right-sided ICD was removed on post-injury day four, and the left ICD was removed on post-injury day five. However, he developed a recurrent left-sided pneumothorax after ICD removal, for which the ICD was reinserted. No air leak was present. Finally, the ICD was removed on post-injury day eight, when chest x-ray (CXR) revealed complete lung expansion, and discharge was contemplated on post-admission day nine. However, the patient suddenly developed a bout of massive hematemesis and went into hemorrhagic shock. He responded to intravenous (IV) fluids and blood products. On clinical examination, a 2x2 cm non-pulsatile swelling was noted near the left angle of the mandible. This time, a CTA demonstrated a large pseudoaneurysm of the left facial artery with an adjacent hematoma that had expanded, reaching the pharyngeal wall [Figure 2].

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Figure 2: CT angiography neck (A) axial and (B) coronal reformatted images done 9 days later show a contrast opacified pouch consistent with pseudoaneurysm (large arrow in A and B) in the medial part of the neck close to the pharyngeal wall with a hematoma/thrombosed lumen of pseudoaneurysm lateral to it (small white arrows in A) reaching up to the skin surface. The facial artery (black arrow in B) is seen as it approaches the pseudoaneurysm. CT: Computed tomography.

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A Digital subtraction angiography (DSA) confirmed the findings. Selective coil embolization of the pseudoaneurysm was successful [Figure 3] Given the pneumopericardium, we closely monitored cardiac function, which might have deteriorated with a new episode of hemorrhagic shock. We reinitiated nasogastric tube feeding after angioembolization. Oral feeds were introduced in a phased manner, with an emphasis on solid meals. The remainder of his hospital stay was uneventful. He was discharged after echocardiography showed normal cardiac function and complete resolution of the pneumopericardium. At outpatient follow-up two months post-discharge, the patient was doing well without significant symptoms, and the neck hematoma had resolved completely.

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Figure 3: (A) DSA images show filling of the pseudoaneurysm (arrow in A) after selective cannulation of the facial artery. The post-coil embolization image (B) shows the coil (arrows) in the facial artery and non-opacification of the pseudoaneurysm distal to it. DSA: Digital subtraction angiography.

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DISCUSSION

Penetrating injuries involving both the chest and neck pose a unique clinical challenge, as each region carries independent life-threatening risks and may evolve differently over time. Management, therefore, requires not only initial prioritization but also a balance between treatment approaches for all injured regions. In our patient, the challenge was to decide on selective NOM in the presence of injuries with potentially divergent and delayed complications.

Pneumopericardium following penetrating chest trauma is an uncommon but recognized entity, and its clinical course can vary widely. While some patients remain entirely stable, others may deteriorate rapidly due to tension physiology or cardiac tamponade. In the present case, the patient remained hemodynamically stable, had no precordial wounds, and showed no echocardiographic evidence of tamponade. In hemodynamically stable patients, several reports have demonstrated that NOM can be safely undertaken when accompanied by continuous monitoring and immediate access to surgical or interventional rescue. We performed a thorough digital search using keywords such as ‘traumatic pneumopericardium’ and ‘penetrating injury pneumopericardium’ and found only 16 publications on the subject, which are shown in Table 1.^2,4-18 Demetriades et al. and Nicol et al. conducted the only prospective studies on patients with traumatic pneumopericardium, and both present contrasting opinions on management.^2,7 While the former managed 19 out of 20 patients successfully nonoperatively, the latter performed a SPW even in stable patients and recommended it as the treatment of choice in stable patients to avoid delayed tension pneumopericardium. As the penetrating chest wounds in our patient were not over the precordium, no direct cardiac injury was suspected. The Macklin effect could explain the pneumopericardium, with air travelling along the peribronchial and perivascular sheaths.¹⁹ Also, secondary to disruption of the visceral pleura, if air dissects into the pulmonary hilum, it may pass into the pericardial sac. In our patient, hemodynamic stability, absence of precordial wounds, and lack of echocardiographic evidence of tamponade supported an initial conservative approach. This strategy was adopted with the understanding that clinical deterioration could be abrupt and would necessitate prompt intervention.

The initially stable penetrating neck injury illustrates the limitations of a single negative CT angiogram. Current management of penetrating neck trauma has shifted toward a selective, “no-zone” approach based on patient physiology, clinical findings, and CT angiography rather than routine surgical exploration.³ Although the initial CT angiogram in our patient did not demonstrate vascular, airway, or pharyngeal injury, delayed vascular complications following penetrating neck trauma are well described. Occult intimal injuries may not be apparent on early imaging and can evolve into pseudoaneurysms or delayed hemorrhage. The sudden episode of hematemesis several days after injury was most consistent with such an evolving vascular lesion, likely in association with a minor pharyngeal wall injury. The absence of early upper gastrointestinal symptoms suggested that any initial pharyngeal injury was limited. This observation is in keeping with published series reporting successful non-operative management of selected pharyngeal injuries.^20,21 This case highlights the importance of ongoing clinical vigilance rather than relying solely on imaging, particularly when multiple injury regions compete for clinical attention.

The availability of endovascular intervention played a pivotal role in management. As a Level 1 Trauma Centre with round-the-clock interventional capabilities, we were able to rush the patient for a prompt intervention, avoiding a potentially complex neck exploration in zone 3, which is difficult to approach surgically. Moreover, operative exploration performed nine days after the primary injury might have included ligation of the external carotid artery as a damage-control procedure. This underscores the importance of institutional resources in determining the safety and feasibility of selective non-operative approaches.

When penetrating chest and neck injuries coexist, heightened attention to one injury can inadvertently overshadow evolving pathology in another region. This case serves as a reminder that selective NOM must remain active, with parallel surveillance strategies for all injured regions. While similar injury patterns and management approaches have been described, this case highlights the practical challenges of monitoring patients with multisystem penetrating trauma and the importance of timely reassessment when delayed complications occur.^5,9

CONCLUSION

Selective NOM is feasible in a hemodynamically stable patient with concurrent penetrating chest and neck injuries, including pneumopericardium and delayed cervical vascular complications. Successful outcomes depend on careful patient selection, structured surveillance, and continuous reassessment. Importantly, such an approach is appropriate only in settings with immediate access to advanced imaging, interventional radiology, and surgical backup, where timely escalation of care can be ensured when delayed complications arise. NOM of patients with multisystem involvement following penetrating injury requires equal attention to all injured regions when managing the patient as a whole.