Abstrak Tension pnemothorax adalah kondisi mengancam nyawa yang membutuhkan jarum untuk dekompresi.

Ruptur diafragma adalah cedera yang relatif jarang terjadi dan sulit untuk di diagnosis. Kombinasi dari tension pneumothorax dan ruptur diafragma ipsilateral dapat dikatakan sebagai life saving. Karena udara dari diafragma akan berpindah ke dalam kavum abdomen. Diagnosis ruptur diafragma dengan computed tomography atau thoracoscopy atau laparoscopy krusial harus dilakukan. Reparasi secara pembedahan harus dilakukan karena rupture tersebut tidak akan menutup secara spontan dan meningkatkan resiko untuk hiatal hernia. Adanya pemasangan suction atau chest tube dapat menyebabkan migrasi organ abdominal atau perforasi iatrogenik. Latar belakang Kami melaporkan pasien dengan traumatik tension pneumothorax sinistra yang disebabkan oleh fraktur kosta. Hasil CT-Scan juga menunjukkan adanya ruptur diafragma. Kami melaporkan pendekatan konservatif dengan chest tube yang menyebabkan perforasi colon diatas diafragma dan menyebabkan fecopneumothorax (kavum thorax berisi feces). tinjauan ini dibuat berdasarkan diagnosis dan terapi post traumatik tension pneumothorax dengan ruptur diafragma. Kami juga mereview permasalahan dalam diagnosis dari ruptur diafragma. Persentasi kasus Pasien lelaki berumur 92 tahun dirujuk ke instalasi gawat darurat oleh dokter umum karena dicurigai pneumonia. Pasien melaporkan sesak yang bertambah parah dan nyeri bilateral pada basis thorax. Empat minggu sebelumnya pasien jatuh dari tangga dan semenjak itu dia menderita nyeri punggung bagian tengah. Pada pemeriksaan fisik didapatkan pernafasan takipnea, penurunan suara nafas pada dada kiri, dan pengembangan paru yang tidak sama/pergerakan dada tidak simetris antara kanan dan kiri. suara jantung reguler takikardia (100x/mnt). Dan peningkatan tekanan vena jugularis. Pemeriksaan abdomen menunjukkan distensi dengan hipoperistaltik, tanpa disertai nyeri tekan. Pada pemerksaan foto x-ray dada (gambar 1) terlihat tension pneumothorax sinistra dengan efusi pleura pada sisi kiri dengan fraktur pada 3 kosta. Secara mengejutkan juga ditemukan bentukan pneumoperitoneum. Dekompresi dengan jarum di bagian kiri segera dilakukan. Dilanjutkan dengan apical chest tube (pemasangan chest tube pada daerah apeks). Dari pemasangan chest tube didapatkan sekitar 500ml darah dan cairan tubuh dengan bentukan
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serous. Prosedur CT-scan dilakukan untuk mencari asal dari udara intra abdominal. Dan ruptur diafragma kiri bagian posterolateral ditemukan dan dengan pertimbangan usia pasien maka dipilih terapi secara konservatif . Pasien di rawat di ICU dan basal chest tube dipasang (chest tube pada ics 4-5) dan diberikan antibiotik spektrum luas. Chest tube diatur pada keadaan menghisap (-10 CM H2O) untuk mempercepat proses penyembuhan. Pada hari ketujuh cairan berwarna coklat terlihat dari chest tube. CT-Scan kembali dilakukan dan menunjukkan herniasi colon transversum melalui defek dari diafragma kiri yang ditemukan pada awal pemeriksaan (Gambar 2) . Chest tube tersebut telah membuat perforasi pada colon, dan menciptakan fecopneumothoraks sinistra. Laparoskopi telah direncanakan. Dalam prosedur ini bagian colon yang mengalami herniasi dan perforasi diangkat, setelah itu prosedur lavase transdiafragmatik dilakukan dan omentum digunakan untuk menutup defek dari diafragma (Gambar 3 dan 4). Mesh atau jahitan tidak digunakan karena abdomen terkontaminasi oleh feces. Pasien berumur 92 tahun tersebut akhirnya meninggal pada hari ke empat post operatif karena insufisensi nafas. Baik pasien dan keluarganya menyatakan menolak tindakan invasif lebih lanjut.

Gambar 1 : Foto Rontgen dada menunjukkan tension pneumothorax kiri dengan pergeseran mediastinum ke kanan, efusi pleura kiri dan fraktur kosta basal pada bagian dorsolateral.

Gambar 2 : CT-Scan pada hari ketujuh menunjukkan gambaran usus (colon transversum) dan feces (panah) serta basal chest tube pada kavum thorax.

Gambar 3 : Foto Peroperatif : Ruptur diafragma posterior kiri .

Gambar 4 Foto Peroperatif : Colon Transversum Menghilang melalui defek diafragma.

Diskusi Tension pneumothorax adalah akumulasi udara yang menyebabkan tekanan dalam ruang pleura meningkat. udara ini dihasilkan oleh katup satu arah (ventil). Diagnosis dikatakan ditegakkan secara klinis karena termasuk dalam kondisi yang dapat mengancam jiwa. Dekompresi jarum segera dilaksanakan sebelum prosedur foto x-ray. Prosedur foto xray dilakukan ketika hemodinamik pasien tidak stabil. Insidens dari cedera diafragma pada trauma tumpul abdomen dan thoraks sekitar 3-5%. Pada kasus ini kami mencurigai bahwa ruptur diafragma yang terjadi pada pasien ini terjadi karena kejadian jatuh dari tangga 4 minggu yang lalu sebelumnya. Memang benar bahwa kebanyakan ruptur diafragma terjadi karena kecelakaan dengan kecepatan tinggi, akan tetapi kecelakaan kecil seperti jatuh juga dapat menyebabkan cedera yang sama. Etiologi yang lain adalah trauma lain sebelumnya atau defek diafragma posterolateral kongenital (bochdalek). Interval antara cedera diafragma dan onset gejala bervariasi mulai dari beberapa minggu sampai beberapa tahun. Rupture sebelah kiri terjadi dua kali lebih sering daripada sisi sebelah kanan dikarenakan adanya proteksi dari hepar. Ketika mencurigai ruptur diafragma maka radiografi dada harus segera dilakukan karena masih menjadi salah satu teknik diagnosa yang paling sensitif. Pada CT-Scan dapat menunjukkan gambaran dari diskontinuitas diafragma tapi hasil itu tidak 100% tepat. Herniasi intra abdominal ke atas diafragma adalah komplikasi yang mungkin terjadi dalam kasus ruptur diafragma. Pembedahan diperlukan karena defek yang terjadi pada diafragma tidak akan menutup secara spontan. Ruptur diafragma yang tidak terdiagnosis atau tidak diperbaiki dapat menimbulkan hernia dikemudian hari. Diagnosis awal sangatlah penting. Hal ini terbukti pada studi retrospektif hernia pada diafragma akibat trauma tembus. Angka mortalitas pada pasien yang terdiagnosis pada awal kejadian adalah 3% dibandingkan 25% pada pasien yang tidak langsung terdiagnosis (dengan rata-rata 27 bulan). Fecopneumothorax atau gastrothorax jarang terjadi dan mungkin menunjukkan gejala yang sama dari tension pneumothorax . Pada kasus ini tension pneumothorax adalah akibat dari fraktur kosta. Fraktur kosta dorsolateral menusuk ke paru-paru kiri. Hipotesis yang mengajukan bahwa tension pneumothorax yang terjadi adalah tension fecopneumothorax karena perforasi kolon sebelumnya yang terjadi diatas diafragma tidak dapat ditegakkan karena tidak adanya feces atau perkembangan bakteri pada penghisapan cairan pertama kali. Tension fecopneumothorax adala kasus yang sangat jarang, sejauh ini baru 12 kasus yang dipublikasikan. Preforasi dari kolon transversus terjadi karena suction pada chest tube pada masa yang lama. Seperti yang dibuktikan pada
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kasus ini penggunaan suction jangka panjang dapat menyebabkan herniasi organ intra abdominal bahkan perforasi jika ada ruptur diafragma. Kesimpulan Pada kasus ini gambaran tension pneumothorax merupakan proses subakut karena udara dapat melewati lubang dan masuk ke dalam abdomen yang terbentuk akibat ruptur diafragma. Tension pneumothorax dengan ruptur diafragma dapat dikatakan kombinasi yang menyelamatkan jiwa. Akan tetapi defek dari diafragma menyebabkan herniasi kolon satu minggu setelahnya lalu terjadi perforasi kolon karena pemasangan chest tube dengan suction . Ketika tension pneumothorax secara pemeriksaan klinis dicurigai maka dekompresi jarum harus segera dilakukan. Pada kasus dimana tidak ada gangguan haemodinamik bijaksana untuk melakukan rontgen dada emergensi sebelum intervensi dilakukan. Setelah itu foto rontgen dada standar dilakukan untuk mencari tanda-tanda herniasi diafragma : elevasi dari hemidiafragma atau gambaran usus pada cavum thorax. Nasogastric tube dapat dilihat pada kavum thorax jika ada herniasi dari lambung. Ketika ada kecurigaan ruptur diafragma, laparoscopy atau thoracoscopy harus dilakukan walaupun hasil CT-Scan menunjukkan hasil negatif. Pendekatan secara hati-hati pada prosedur laparoscopy harus dilakukan. laparoscopy pada pasien dengan ruptur diafragma dapat menimbulkan tension pneumothorax iatrogenik. Ruptur diafragma diperbaiki dengan adanya pemasangan chest tube karena suction pada prosedur tersebut dapat menyebabkan herniasi iatrogenik intra abdominal dan bahkan terjadi perforasi usus. Persetujuan Penulisan inform consent diperoleh dari pasien untuk publikasi dari case report ini dan setiap gambar yang menyertainya. Salinan persetujuan tertulis tersedia untuk ditinjau oleh kepala editor jurnal ini. Penulis yang berkonstribusi SP menyusun naskah. SDC membuat revisi substansial. Kedua penulis telah direvisi, membaca dan menyetujui artikel.

Referensi 1. Nishijima D, Zehbtachi S, Austin RB: Acute posttraumatic tension gastrothorax mimicking acute tension pneumothorax. Am J Emerg Med 2007, 25(6):734.e5-6. 2. Cern Navarro J, Pealver Cuesta JC, Padilla Alarcn J, Jord Aragn C, Escriv Peir J, Calvo Medina V, Garca Zarza A, Pastor Guillem J, Blasco Armengod E: Traumatic rupture of the diaphragm. Arch Bronconeumol 2008, 44(4):197-203. 3. Vermillion JM, Wilson EB, Smith RW: Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax. Hernia 2001, 5(3):158-160. 4. Chen JC, Wilson SE: Diaphragmatic injuries: recognition and management in sixtytwo patients. Am Surg 1991, 57:810. 5. Shackleton KL, Stewart ET, Taylor AJ: Traumatic diaphragmatic injuries: spectrum of radiographic findings. Radiographics 1998, 18:49-59. 6. Degiannis E, Levy RD, Sofianos C, Potokar T, Florizoone MG, Saadia R: Diaphragmatic herniation after penetrating trauma. Br J Surg 1996, 83:88-91. 7. Azagury DE, Karenovics W, Sthli DM, Mathis J, Schneider R: Management of acute gastrothorax with respiratory distress: insertion of nasogastric tube as a life saving procedure. Eur J Emerg Med 2008, 15(6):357-358. 8. Ramdass MJ, Kamal S, Paice A, Andrews B: Traumatic diaphragmatic herniation presenting as a delayed tension faecopneumothorax. Emerg Med J 2006, 23(10):e54. 9. Jarry J, Razafindratsira T, Lepront D, Pallas G, Eggenspieler P, Dastes FD: Tension faecopneumothorax as the rare presenting feature of a traumatic diaphragmatic hernia. Ann Chir 2006, 131(1):48-50. Epub 2005 Aug 15

Case report

Tension pneumothorax and life saving diaphragmatic rupture: a case report and review of the literature
Sylvain AA Pilate1* and Stefaan De Clercq2

* Corresponding author: Sylvain AA Pilate sylvain.pilate@skynet.be Author Affiliations

1

Department of emergency, University hospital Antwerp, Wilrijkstraat 10, 2650 Edegem,

Belgium
2

Department of surgery, ZNA Stuivenberg - Erasmus, Antwerp, Belgium

For all author emails, please log on. World Journal of Emergency Surgery 2011, 6:23 doi:10.1186/1749-7922-6-23

The electronic version of this article is the complete one and can be found online at: http://www.wjes.org/content/6/1/23

Received: Accepted: Published:

27 May 2011 1 August 2011 1 August 2011

2011 Pilate and De Clercq; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract
A tension pneumothorax is a known life-threatening condition which requires a needle decompression. A diaphragmatic rupture is a relatively rare injury and is difficult to diagnose. A combination of a tension pneumothorax in presence of an ipsilateral diaphragmatic rupture can be called life-saving since the air in the pleural space is able to escape to the abdomen. The diagnosis of a diaphragmatic rupture by computed tomography or even by laparo- or thorascopy is crucial. Surgical repair should always be undertaken because the rupture will not close spontaneously and the risk of herniation of intraabdominal organs to the pleural space will remain. In presence of a chest tube on suction, iatrogenic migration or even perforation of these organs can occur.
Keywords:

Tension pneumothorax; diaphragmatic rupture; diaphragmatic hernia; fecopneumothorax

Background
We describe a patient who presented with a traumatic left tension pneumothorax secondary to rib fractures. A computed tomography also showed a posterior left diaphragmatic rupture. We report a conservative approach with chest tubes that led to iatrogenic colonic perforation above the diaphragm after one week, thus creating a fecopneumothorax. A review is made on the diagnosis and treatment of post-traumatic tension pneumothorax with concomitant diaphragmatic rupture. We also review the pitfalls of the diagnosis of diaphragmatic ruptures.

Case presentation
A 92-year-old man was referred to the emergency department by his general practitioner because of suspicion of pneumonia. The patient reported increasing dyspnoea and bilateral pain at the thoracic base. Four weeks earlier he fell from the stairs and since then he suffered from mid-dorsal back pain. Physical examination of the lungs revealed tachypnoea, decreased breath sounds on the left side and unequal chest rise. Heart auscultation demonstrated regular rate tachycardia (110 bpm). The jugular venous pressure was raised. Abdominal examination showed a distended abdomen with hypoperistalsis, but no tenderness. On a chest x-ray a left tension pneumothorax was seen with pleural effusion on the left side and three recent basal dorsolateral rib fractures. Surprisingly a pneumoperitoneum was also visible on the chest x-ray (Figure 1). Needle decompression
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was immediately executed. Subsequently an apical chest tube was inserted on the left side and approximately 500 ml of serous and bloody fluid was drained. A computed tomography was made in search of the origin of intra-abdominal air. A left posterolateral diaphragmatic rupture was found. In respect to the patient's age a conservative approach was chosen. He was admitted to the intensive care unit and a second basal chest tube was inserted on the left side and broad spectrum antibiotics were administered. The chest tubes were kept on suction (-10 cm H2O) to accelerate the rate of healing. On the seventh day brown liquid was observed from the basal chest tube. A new computed tomography was performed and this showed herniation of the transverse colon through the hernia defect in the left diaphragm (Figure 2). The basal chest tube had perforated the colon, thus creating a left fecopneumothorax. A laparoscopic repair was planned. During this procedure the herniated and perforated part of the colon was removed, a transdiaphragmatic lavage was undertaken and the omentum was used to close the diaphragmatic defect (Figures 3 and 4). A mesh or sutures were not used since the abdomen was contaminated with feces. The 92year-old-patient deceased on the fourth post-operative day due to respiratory insufficiency. Both the patient and family were in consent for abstinence from further invasive therapy.

Figure 1. Initial chest x-ray showing a left tension pneumothorax with shift of the mediastinum to the right, pleural effusion left, basal dorsolateral rib fractures. There's also air visible under the right diaphragm (arrow).

Figure 2. Computed tomography on the seventh day showing intrathoracic presence of bowel (colon transversum) with feces (arrow) and a basal chest tube.

Figure 3. Peroperative picture: left posterior diaphragmatic rupture.

Figure 4. Peroperative picture: colon transversum disappearing trough the diaphragmatic defect.

Discussion
A tension pneumothorax is the accumulation of air causing a pressure rise in the pleural space, generated by a unidirectional valve mechanism. The diagnosis is said to be clinical since it results in a life-threatening condition. Emergent needle decompression should be carried out before confirmation by chest x-ray when the patient is haemodynamic instable.
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The incidence of diaphragmatic injury among patients with blunt thoracic and abdominal trauma is about 3%-5% [1]. In this case we suspect that the left diaphragmatic injury resulted from the patient's fall from the stairs four weeks before his arrival at the emergency department. It is true that most diaphragmatic ruptures are due to high speed traffic accidents, but smaller accidents like a fall can cause the same type of injury [2]. Other etiologies might be an earlier trauma or a congenital posterolateral hernia (Bochdalek). The interval between diaphragmatic injury and the onset of symptoms can range from several weeks to years [3]. Left-sided rupture occurs approximately twice as often as right sided, due to protection of the liver [4]. When a traumatic diaphragmatic rupture is suspected a chest radiograph should be obtained because it remains the most sensitive method for diagnosis [5]. A computed tomography may show a discontinuity of the diaphragm, but it is not 100% sensitive. Herniation of intra-abdominal organs above the diaphragm is a possible complication of a diaphragmatic rupture. Surgical repair is necessary because the rupture will not close spontaneously. An undiagnosed or unrepaired diaphragmatic rupture can cause future hernation of intra-abdominal organs. Early diagnosis is crucial which was proven in a retrospective study with diaphragmatic herniation after penetrating trauma. The mortality rate in the group with early presentation was 3% compared to 25% in the group with delayed presentation (with a median of 27 months) [6]. A fecopneumothorax or a gastrothorax may rarely occur and may mimick the clinical presentation of a tension pneumothorax [3,7]. In this case the tension pneumothorax was secondary to rib fractures. The dorsolateral rib fractures were pointing towards the left lung. The hypothesis that the initial tension pneumothorax was a tension fecopneumothorax due to earlier colonic perforation above the diaphragmatic hernia was not withheld because of absence of feces or bacterial growth in the initial drainage fluid. A tension fecopneumothorax is a very rare identity and so far only 12 case reports have been published [8,9]. The perforation of the transverse colon was due to prolonged suction on the chest tube thus causing adherence and perforation of the herniated colon, resulting in a fecopneumothorax. As proven in this case a chest tube under prolonged suction might create an iatrogenic herniation of intra-abdominal organs and even perforation when a diaphragmatic rupture is present.

Conclusion
In this case the presentation of the tension pneumothorax was subacute because the air was able to escape through the diaphragmatic rupture towards the peritoneum. A tension pneumothorax in presence of an ipsilateral diaphragmatic rupture can be called a life10

saving combination. Unfortunately this diaphragmatic defect led to colonic herniation after one week thus allowing a chest tube to perforate the colon through suction. When a traumatic tension pneumothorax is clinically suspected a needle decompression should be performed. In the absence of haemodynamic compromise, it is prudent to wait for the results of an emergent chest x-ray prior to intervention. Afterwards a standard chest radiograph helps to look for signs of diaphragmatic herniation: elevation of the hemidiaphragm or the presence of bowel or stomach in the chest. A nasogastric tube can be seen above the diaphragm in herniation of the stomach. When a diaphragmatic rupture is suspected a laparoscopy or thoracosopy should be performed even with a negative computed tomography. A cautious approach is advised because a laparoscopy undertaken on a patient with a diaphragmatic rupture can lead to an iatrogenic tension pneumothorax. A diaphragmatic rupture must be repaired in presence of chest tubes as suction might cause iatrogenic herniation of intra-abdominal organs leading to perforation.

Consent
Written informed consent was obtained from the the patient's relative for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal

Competing interests
The authors declare that they have no competing interests.

Authors' contributions
SP drafted the manuscript. SDC made substantial revisions. Both authors have revised, read and approved the article.

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References
1. Nishijima D, Zehbtachi S, Austin RB: Acute posttraumatic tension gastrothorax mimicking acute tension pneumothorax. Am J Emerg Med 2007, 25(6):734.e5-6. 2. Cern Navarro J, Pealver Cuesta JC, Padilla Alarcn J, Jord Aragn C, Escriv Peir J, Calvo Medina V, Garca Zarza A, Pastor Guillem J, Blasco Armengod E:Traumatic rupture of the diaphragm. Arch Bronconeumol 2008, 44(4):197-203. 3. Vermillion JM, Wilson EB, Smith RW: Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax. Hernia 2001, 5(3):158-160. 4. Chen JC, Wilson SE: Diaphragmatic injuries: recognition and management in sixty-two patients. Am Surg 1991, 57:810. 5. Shackleton KL, Stewart ET, Taylor AJ: Traumatic diaphragmatic injuries: spectrum of radiographic findings. Radiographics 1998, 18:49-59 6. Degiannis E, Levy RD, Sofianos C, Potokar T, Florizoone MG, Saadia R: Diaphragmatic herniation after penetrating trauma. Br J Surg 1996, 83:88-91. 7. Azagury DE, Karenovics W, Sthli DM, Mathis J, Schneider R: Management of acute gastrothorax with respiratory distress: insertion of nasogastric tube as a life saving procedure. Eur J Emerg Med 2008, 15(6):357-358. 8. Ramdass MJ, Kamal S, Paice A, Andrews B: Traumatic diaphragmatic herniation presenting as a delayed tension faecopneumothorax. Emerg Med J 2006, 23(10):e54. 9. Jarry J, Razafindratsira T, Lepront D, Pallas G, Eggenspieler P, Dastes FD: Tension faecopneumothorax as the rare presenting feature of a traumatic diaphragmatic hernia. Ann Chir 2006, 131(1):48-50. Epub 2005 Aug 15

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