Ravi Tripathi, MD
Associate Professor-Clinical
Ohio State University, United States
Disclosure information not submitted.
Andrew Springer, MD
Assistant Professor - Clinical
Ohio State University, United States
Disclosure information not submitted.
Title: Pneumothorax and Left Ventricular Air Resulting in PEA Arrest Immediately Following CT
Introduction: Pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema are serious complications of COPD in the critical care setting that require immediate intervention. While these complications have been previously described in the literature this represents the first case of association with left ventricular air identified on peri-arrest computed tomography.
Description: A 56 year old female with a past medical history of COPD, T1DM (s/p KP transplant), and peripheral vascular disease was admitted to the cardiovascular ICU following a complex LLE thrombectomy. On POD3 the patient was taken back to the OR for repeat thrombectomy for continued ischemia. Following the operation, a chest radiograph was obtained upon readmission to the ICU which notably did not show any signs of pneumothorax. The patent was then taken for CT scan to help guide medical management.
During IV contrast injection for the CT, the patient's ventilator alarmed and immediately following image acquisition the patient became hemodynamically unstable and proceeded to PEA arrest. ACLS was begun and ROSC was obtained after two minutes. After ROSC a pneumothorax was noted on the initial CT scan images and an emergent needle decompression was performed by ICU staff followed by chest tube placement. In addition, a filling defect consistent with air inside of the left ventricle was noted and the patient was placed in trendelenburg positioning. Pneumomediastinum, pneumoperitoneum, subcutaneous emphysema were also noted on the imaging. Later, an echocardiogram was performed by cardiology which showed resolution of the LV air and of note did not identify a PFO.
Discussion: It is difficult to say with certainty the exact etiology of the patients PEA arrest and LV air. A spontaneous pneumothorax is one explanation given the patents underlying emphysematous disease. Case reports have described pneumomediastinum pneumoperitoneum, subcutaneous emphysema with such events, however this is the first description of such an event leading to LV air that could be identified upon literature review. Other etiologies are certainly possible, however it is difficult to attribute all of the events of this case to any single pathology.