Forensic Sci Med Pathol (2015) 11:122–123 DOI 10.1007/s12024-014-9601-4
IMAGES IN FORENSICS
Pneumopericardium as a consequence of air embolism ˇ ivkovic´ • Slobodan Nikolic´ Vladimir Z
Accepted: 2 August 2014 / Published online: 29 August 2014 Ó Springer Science+Business Media New York 2014
Case Report A 34-year-old man committed suicide by jumping from the terrace of his apartment on the tenth floor (approximately 30 m height). His body was found on a grassy field, about 4 m from the building. He died at the scene of the incident. A forensic autopsy was performed the following day. The deceased was 174 cm tall and weighed approximately 65 kg. The external examination of the body revealed multiple skin injuries, predominantly localized to the right half of the head and trunk. There was a large laceration on the right side of the head and open skull fracture, with multiple lacerations of the dura and the brain. One of the fracture lines went across the projection of the right transverse sinus of the dura. There was approximately 2 l of blood in the chest cavity with complete multiple rupture of the thoracic part of the aorta, multiple lung lacerations, as well as numerous bilateral rib fractures. Autopsy also revealed a tense pericardial sac with the presence of the air inside it—pneumopericardium (Fig. 1). Inside the pericardial sac there was also a small amount of the blood (about 50 ml). Examination of the heart revealed complete rupture at the junction of the superior vena cava and the wall of the right atrium, encompassing the anterior and right lateral part of the circumference (Fig. 2). The autopsy also revealed multiple pelvic bone fractures and fractures of the upper part of both femora.
V. Zˇivkovic´ S. Nikolic´ (&) Institute of Forensic Medicine, University of Belgrade - School of Medicine, 31a Deligradska Str., 11000 Belgrade, Serbia e-mail: [email protected]; [email protected]
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All these injuries were consistent with the victim impacting the ground with his legs and the right side of his body. Lacerations of the thoracic aorta and right atrium were indirect due to the deceleration of the body.
Discussion Pneumopericardium is defined as a collection of air or gas in the pericardial cavity and was described by Bricheteau in 1844 [1]. Although a relatively rare condition, cases have been reported in the literature [1, 2]. Pneumopericardium has been reported to result from blunt and penetrating chest trauma, as a complication of invasive iatrogenic procedures, from abnormal pathological communications such as fistulas from the pericardium to the adjacent structures containing air from different causes, from barotrauma, and from pericardial infections [3, 4]. It has also been suggested that shearing forces rupturing the marginal alveolar bases, dissecting the peribronchial and perivascular sheaths with the resulting escape of air peripherally along vessels, could result in pneumopericardium [3, 5]. This mechanism is known as the Macklin effect [5]. The pericardial space may also be connected directly to pleural or tracheobronchial gases as a consequence of a pericardial tear [5]. Sufficient accumulation of pericardial gas may impair right ventricular filling, resulting in pericardial tamponade with an increase and equalization of intracardiac pressures, pulsus paradoxus, arterial hypotension, and cardiogenic shock [3]. Air embolism consists of an interruption of the circulatory system by bubbles of air that gain access to the circulation, usually through the venous side [6]. Every autopsy in a case involving an open wound in the neck area, or open wound of the head, involving a skull fracture
Forensic Sci Med Pathol (2015) 11:122–123
Fig. 1 Tense pericardial sac filled with air in situ, during autopsy
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such as concomitant injuries of trachea, bronchi, lungs, or pericardium. Therefore, pneumopericardium could be a reflection of air embolism that occurred due to open skull fracture with laceration of the right transverse sinus of the dura. Due to rupture at the junction of the superior vena cava and right atrium, instead of going into the right ventricle, and further causing pulmonary air embolism, the air leaked out into pericardial sac, filling it and causing pneumopericardium, clearly visible by the naked eye during autopsy. Estimates of the quantity of air sufficient to cause death from venous air embolism range up to 480 ml [4], i.e. the amount of air is not small, which could explain why, in the presented case, the pericardial sac was tense in gross appearance. The relatively small amount of blood in the pericardial sac could also imply that moments before death occurred air, instead of blood, flowed through the basin of superior vena cava. The presented case shows that, on rare occasions, pneumopericardium could originate from an air embolism caused by an open skull fracture. In this particular case, pneumopericardium could be observed as a vital reaction, but could also indicate the pathophysiological mechanism of injury. Acknowledgments This work was supported by Ministry of Science of Republic of Serbia, Grant No. 45005.
References
Fig. 2 Laceration of the right atrium wall. The tip of the lower pincette is inside the terminal part of the superior vena cava, while the other holds the pulmonary artery
and laceration of the sinuses of the dura should begin with a check for air embolism [7]. In these cases, due to negative pressure in these structures, air is sucked inside the venous system, causing pulmonary air embolism. In such cases, air embolism could be the cause of death, or simply a vital reaction indicating that the victim was still alive when the head or neck injury occurred. In the presented case, the autopsy excluded other possible causes which could have led to pneumopericardium,
1. Bilir O, Yavasi O, Ersunan G, Kayayurt K, Giakoup B. Pneumomediastinum associated with pneumopericardium and epidural pneumatosis. Case Rep Emerg Med. 2014;2014:275490. 2. Ring A, Liebert T, Stern J. Pneumopericardium after hyperemesis. Possible result of the Macklin effect. Chirurg. 2010;81(6):568–71. 3. Brander L, Ramsay D, Dreier D, Peter M, Graeni R. Continuous left hemidiaphragm sign revisited: a case of spontaneous pneumopericardium and literature review. Heart. 2002;88(4):e5. 4. Shkrum M, Ramsay D. Forensic pathology of trauma—common problems for the pathologist. Totowa: Humana Press; 2007. 5. Konijn AJ, Egbers PH, Kuiper MA. Pneumopericardium should be considered with electrocardiogram changes after blunt chest trauma: a case report. J Med Case Rep. 2008;2:100. 6. Saukko P, Knight B. Forensic pathology. 3rd ed. London: Hodder Arnold; 2004. 7. Spitz WU, Fisher RS. Medicolegal investigation of death: Guidelines for the application of pathology to crime investigation. Springfield: Charles C. Thomas; 2006.
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IMAGES IN FORENSICS
Pneumopericardium as a consequence of air embolism ˇ ivkovic´ • Slobodan Nikolic´ Vladimir Z
Accepted: 2 August 2014 / Published online: 29 August 2014 Ó Springer Science+Business Media New York 2014
Case Report A 34-year-old man committed suicide by jumping from the terrace of his apartment on the tenth floor (approximately 30 m height). His body was found on a grassy field, about 4 m from the building. He died at the scene of the incident. A forensic autopsy was performed the following day. The deceased was 174 cm tall and weighed approximately 65 kg. The external examination of the body revealed multiple skin injuries, predominantly localized to the right half of the head and trunk. There was a large laceration on the right side of the head and open skull fracture, with multiple lacerations of the dura and the brain. One of the fracture lines went across the projection of the right transverse sinus of the dura. There was approximately 2 l of blood in the chest cavity with complete multiple rupture of the thoracic part of the aorta, multiple lung lacerations, as well as numerous bilateral rib fractures. Autopsy also revealed a tense pericardial sac with the presence of the air inside it—pneumopericardium (Fig. 1). Inside the pericardial sac there was also a small amount of the blood (about 50 ml). Examination of the heart revealed complete rupture at the junction of the superior vena cava and the wall of the right atrium, encompassing the anterior and right lateral part of the circumference (Fig. 2). The autopsy also revealed multiple pelvic bone fractures and fractures of the upper part of both femora.
V. Zˇivkovic´ S. Nikolic´ (&) Institute of Forensic Medicine, University of Belgrade - School of Medicine, 31a Deligradska Str., 11000 Belgrade, Serbia e-mail: [email protected]; [email protected]
123
All these injuries were consistent with the victim impacting the ground with his legs and the right side of his body. Lacerations of the thoracic aorta and right atrium were indirect due to the deceleration of the body.
Discussion Pneumopericardium is defined as a collection of air or gas in the pericardial cavity and was described by Bricheteau in 1844 [1]. Although a relatively rare condition, cases have been reported in the literature [1, 2]. Pneumopericardium has been reported to result from blunt and penetrating chest trauma, as a complication of invasive iatrogenic procedures, from abnormal pathological communications such as fistulas from the pericardium to the adjacent structures containing air from different causes, from barotrauma, and from pericardial infections [3, 4]. It has also been suggested that shearing forces rupturing the marginal alveolar bases, dissecting the peribronchial and perivascular sheaths with the resulting escape of air peripherally along vessels, could result in pneumopericardium [3, 5]. This mechanism is known as the Macklin effect [5]. The pericardial space may also be connected directly to pleural or tracheobronchial gases as a consequence of a pericardial tear [5]. Sufficient accumulation of pericardial gas may impair right ventricular filling, resulting in pericardial tamponade with an increase and equalization of intracardiac pressures, pulsus paradoxus, arterial hypotension, and cardiogenic shock [3]. Air embolism consists of an interruption of the circulatory system by bubbles of air that gain access to the circulation, usually through the venous side [6]. Every autopsy in a case involving an open wound in the neck area, or open wound of the head, involving a skull fracture
Forensic Sci Med Pathol (2015) 11:122–123
Fig. 1 Tense pericardial sac filled with air in situ, during autopsy
123
such as concomitant injuries of trachea, bronchi, lungs, or pericardium. Therefore, pneumopericardium could be a reflection of air embolism that occurred due to open skull fracture with laceration of the right transverse sinus of the dura. Due to rupture at the junction of the superior vena cava and right atrium, instead of going into the right ventricle, and further causing pulmonary air embolism, the air leaked out into pericardial sac, filling it and causing pneumopericardium, clearly visible by the naked eye during autopsy. Estimates of the quantity of air sufficient to cause death from venous air embolism range up to 480 ml [4], i.e. the amount of air is not small, which could explain why, in the presented case, the pericardial sac was tense in gross appearance. The relatively small amount of blood in the pericardial sac could also imply that moments before death occurred air, instead of blood, flowed through the basin of superior vena cava. The presented case shows that, on rare occasions, pneumopericardium could originate from an air embolism caused by an open skull fracture. In this particular case, pneumopericardium could be observed as a vital reaction, but could also indicate the pathophysiological mechanism of injury. Acknowledgments This work was supported by Ministry of Science of Republic of Serbia, Grant No. 45005.
References
Fig. 2 Laceration of the right atrium wall. The tip of the lower pincette is inside the terminal part of the superior vena cava, while the other holds the pulmonary artery
and laceration of the sinuses of the dura should begin with a check for air embolism [7]. In these cases, due to negative pressure in these structures, air is sucked inside the venous system, causing pulmonary air embolism. In such cases, air embolism could be the cause of death, or simply a vital reaction indicating that the victim was still alive when the head or neck injury occurred. In the presented case, the autopsy excluded other possible causes which could have led to pneumopericardium,
1. Bilir O, Yavasi O, Ersunan G, Kayayurt K, Giakoup B. Pneumomediastinum associated with pneumopericardium and epidural pneumatosis. Case Rep Emerg Med. 2014;2014:275490. 2. Ring A, Liebert T, Stern J. Pneumopericardium after hyperemesis. Possible result of the Macklin effect. Chirurg. 2010;81(6):568–71. 3. Brander L, Ramsay D, Dreier D, Peter M, Graeni R. Continuous left hemidiaphragm sign revisited: a case of spontaneous pneumopericardium and literature review. Heart. 2002;88(4):e5. 4. Shkrum M, Ramsay D. Forensic pathology of trauma—common problems for the pathologist. Totowa: Humana Press; 2007. 5. Konijn AJ, Egbers PH, Kuiper MA. Pneumopericardium should be considered with electrocardiogram changes after blunt chest trauma: a case report. J Med Case Rep. 2008;2:100. 6. Saukko P, Knight B. Forensic pathology. 3rd ed. London: Hodder Arnold; 2004. 7. Spitz WU, Fisher RS. Medicolegal investigation of death: Guidelines for the application of pathology to crime investigation. Springfield: Charles C. Thomas; 2006.
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![[CT findings of a cerebral air embolism as a consequence of an accidental subclavian catheter disconnection].](/assets/img/hold.png)
