Intensive Care Med (2014) 40:1055–1056 DOI 10.1007/s00134-014-3300-1
Ce´dric Carrie´ Nicolas Morel Franc¸ois Delaunay Philippe Revel Matthieu Biais
LETTER
computed tomography (CT) scan revealed multiple ribs fractures and pulmonary contusions without sepsis or respiratory failure. Moderate mediastinal air was attributed to the fractures and/or lung trauma, as no obvious aerodigestive perforation was Noninvasive ventilation in blunt identified (Fig. 1a). The initial manconsisted of effective pain chest trauma: beware of missed agement control by epidural analgesia and esophageal injuries! early NIV to prevent secondary respiratory failure. After 48 hours of Accepted: 9 April 2014 intensive care, the constitution of a Published online: 1 May 2014 pleural effusion and emergence of a Ó Springer-Verlag Berlin Heidelberg and septic shock motivated a second CT ESICM 2014 scan, which revealed an increase of pneumomediastinum due to a large esophageal perforation (Fig. 1b). The patient was then transferred for suture Dear Editor, of esophageal perforation and effecFor several years, there has been an tive pleural and mediastinal drainage. exponential use of noninvasive ven- After treatment of the septic shock, a tilation (NIV) for the treatment or favourable outcome allowed disprevention of acute respiratory fail- charge of the patient after 15 days of ure, while the actual benefit has not intensive care. been fully documented for all appliTo our knowledge, this is the first cations [1–4]. In blunt chest trauma published report of esophageal perpatients, early use of NIV has been foration associated with an shown to prevent intubation and inappropriate use of NIV in blunt decrease overall complications [4]. chest trauma patients. Traumatic However, an inappropriate use in esophageal perforation is an extrenonselected patients can raise the mely rare event associated with an concern of potentially lethal compli- important morbidity and mortality cations due to initially missed [5]. For the diagnosis, the gold stanaerodigestive injuries. dard remains a water-soluble contrast Thus we report the case of a swallow, but this investigation 26-year-old patient admitted in our requires a cooperative patient. In trauma center after a blunt chest ventilated patients, flexible esophatrauma due to high-speed motorgoscopy should be used. Thoracic vehicle accident. The whole body CT-scan can also be a useful
Fig. 1 a Initial thoracic CT scan finding a left pulmonary contusion associated with a small pneumomediastinum without significant aerodigestive injury. b Second thoracic CT scan 2 days later, revealing a significant increase of pneumomediastinum secondary to a 3 cm distal thoracic esophageal perforation
diagnostic modality when allowing direct visualization of esophageal disruption. However, subtle perforations may be missed, especially at the early stage. CT-scan often provides non-specific signs often ascribed to more common blunt thoracic injuries. Indeed, pneumomediastinum is not uncommon in the polytrauma patients, but has been found to have little clinical significance to predict aerodigestive tract injuries. Thus, it can be difficult to justify a systematic endoscopy in front of a pneumomediastinum in the absence of another argument for esophageal perforation in the initial phase of trauma. Consequently, delayed diagnosis of esophageal perforation is very frequent, reaching 50 % in some series [5]. Then, imaging examinations should be controlled in case of persistent diagnostic uncertainty or clinical worsening. Whatever the diagnosis strategy, it is necessary to avoid iatrogenic injury by improper increase in esophageal pressure, as the diagnosis of esophageal injury is not eliminated. In conclusion, this case emphasizes the need for vigilance in the detection of uncommon esophageal injuries when NIV should be indicated in blunt chest trauma patients. Thus, when CT scan cannot rule out traumatic esophageal injury, NIV should be delayed to perform systematic evaluation with more specific esophageal imaging within 12–24 h.
1056
Conflicts of interest Authors declare no 3. Antonelli M, Conti G, Bello G (2013) conflicts of interest. New niches for NIV: ahead with caution! Intensive Care Med 39:1325–1327 4. Chiumello D, Coppola S, Froio S, Gregoretti C, Consonni D (2013) References Noninvasive ventilation in chest trauma: systematic review and meta-analysis. Intensive Care Med 39:1171–1180 1. Rucci G, Casale T, Nava S (2013) First 5. Ivatury RR, Moore FA, Biffl W, use of noninvasive ventilation during Leppeniemi A, Ansaloni L, Catena F, urgent coronary stenting in acute Peitzman A, Moore EE (2014) myocardial infarction complicated by Oesophageal injuries: position paper, pulmonary edema. Intensive Care Med WSES, 2013. World J Emerg Surg 9:9 39:1166–1167 2. Laghi F, Fernandez R (2012) Noninvasive ventilation for weaning in hypoxemic respiratory failure: not ready for prime time. Intensive Care Med 38:1583–1585
C. Carrie´ ()) N. Morel F. Delaunay P. Revel Emergency Department, CHU de Bordeaux, 33000 Bordeaux, France e-mail: [email protected] M. Biais Anaesthesiology Department, CHU de Bordeaux, 33000 Bordeaux, France M. Biais Universite´ Bordeaux Segalen, 33000 Bordeaux, France
Ce´dric Carrie´ Nicolas Morel Franc¸ois Delaunay Philippe Revel Matthieu Biais
LETTER
computed tomography (CT) scan revealed multiple ribs fractures and pulmonary contusions without sepsis or respiratory failure. Moderate mediastinal air was attributed to the fractures and/or lung trauma, as no obvious aerodigestive perforation was Noninvasive ventilation in blunt identified (Fig. 1a). The initial manconsisted of effective pain chest trauma: beware of missed agement control by epidural analgesia and esophageal injuries! early NIV to prevent secondary respiratory failure. After 48 hours of Accepted: 9 April 2014 intensive care, the constitution of a Published online: 1 May 2014 pleural effusion and emergence of a Ó Springer-Verlag Berlin Heidelberg and septic shock motivated a second CT ESICM 2014 scan, which revealed an increase of pneumomediastinum due to a large esophageal perforation (Fig. 1b). The patient was then transferred for suture Dear Editor, of esophageal perforation and effecFor several years, there has been an tive pleural and mediastinal drainage. exponential use of noninvasive ven- After treatment of the septic shock, a tilation (NIV) for the treatment or favourable outcome allowed disprevention of acute respiratory fail- charge of the patient after 15 days of ure, while the actual benefit has not intensive care. been fully documented for all appliTo our knowledge, this is the first cations [1–4]. In blunt chest trauma published report of esophageal perpatients, early use of NIV has been foration associated with an shown to prevent intubation and inappropriate use of NIV in blunt decrease overall complications [4]. chest trauma patients. Traumatic However, an inappropriate use in esophageal perforation is an extrenonselected patients can raise the mely rare event associated with an concern of potentially lethal compli- important morbidity and mortality cations due to initially missed [5]. For the diagnosis, the gold stanaerodigestive injuries. dard remains a water-soluble contrast Thus we report the case of a swallow, but this investigation 26-year-old patient admitted in our requires a cooperative patient. In trauma center after a blunt chest ventilated patients, flexible esophatrauma due to high-speed motorgoscopy should be used. Thoracic vehicle accident. The whole body CT-scan can also be a useful
Fig. 1 a Initial thoracic CT scan finding a left pulmonary contusion associated with a small pneumomediastinum without significant aerodigestive injury. b Second thoracic CT scan 2 days later, revealing a significant increase of pneumomediastinum secondary to a 3 cm distal thoracic esophageal perforation
diagnostic modality when allowing direct visualization of esophageal disruption. However, subtle perforations may be missed, especially at the early stage. CT-scan often provides non-specific signs often ascribed to more common blunt thoracic injuries. Indeed, pneumomediastinum is not uncommon in the polytrauma patients, but has been found to have little clinical significance to predict aerodigestive tract injuries. Thus, it can be difficult to justify a systematic endoscopy in front of a pneumomediastinum in the absence of another argument for esophageal perforation in the initial phase of trauma. Consequently, delayed diagnosis of esophageal perforation is very frequent, reaching 50 % in some series [5]. Then, imaging examinations should be controlled in case of persistent diagnostic uncertainty or clinical worsening. Whatever the diagnosis strategy, it is necessary to avoid iatrogenic injury by improper increase in esophageal pressure, as the diagnosis of esophageal injury is not eliminated. In conclusion, this case emphasizes the need for vigilance in the detection of uncommon esophageal injuries when NIV should be indicated in blunt chest trauma patients. Thus, when CT scan cannot rule out traumatic esophageal injury, NIV should be delayed to perform systematic evaluation with more specific esophageal imaging within 12–24 h.
1056
Conflicts of interest Authors declare no 3. Antonelli M, Conti G, Bello G (2013) conflicts of interest. New niches for NIV: ahead with caution! Intensive Care Med 39:1325–1327 4. Chiumello D, Coppola S, Froio S, Gregoretti C, Consonni D (2013) References Noninvasive ventilation in chest trauma: systematic review and meta-analysis. Intensive Care Med 39:1171–1180 1. Rucci G, Casale T, Nava S (2013) First 5. Ivatury RR, Moore FA, Biffl W, use of noninvasive ventilation during Leppeniemi A, Ansaloni L, Catena F, urgent coronary stenting in acute Peitzman A, Moore EE (2014) myocardial infarction complicated by Oesophageal injuries: position paper, pulmonary edema. Intensive Care Med WSES, 2013. World J Emerg Surg 9:9 39:1166–1167 2. Laghi F, Fernandez R (2012) Noninvasive ventilation for weaning in hypoxemic respiratory failure: not ready for prime time. Intensive Care Med 38:1583–1585
C. Carrie´ ()) N. Morel F. Delaunay P. Revel Emergency Department, CHU de Bordeaux, 33000 Bordeaux, France e-mail: [email protected] M. Biais Anaesthesiology Department, CHU de Bordeaux, 33000 Bordeaux, France M. Biais Universite´ Bordeaux Segalen, 33000 Bordeaux, France
