Pneumoperitoneum Secondary to Pneumothorax Post-Intubation in a Patient with Difficult Airway

The use of mechanical ventilation can be performed in situations where patients need ventilatory support to maintain adequate oxygenation. Its inappropriate use can cause some complications, among them: pneumothorax and pneumoperitoneum. Our report describes a 28-year-old man admitted to the ICU with a diagnosis of Covid-19 requiring mechanical ventilation with orotracheal intubation due to acute respiratory failure. During the patient’s clinical evolution he presented bilateral pneumothorax with evolution and progression to secondary pneumoperitoneum, where we sought to understand the relationship between the two conditions.

Spontaneous Pneumothorax Mimicking Perforated Viscus in Covid-19 patient

Case presentation: A 65-year-old female diagnosed with COVID-19 developed worsening respiratory distress requiring invasive ventilation. Chest radiography post-intubation revealed air under the diaphragm, pneumomediastinum and subcutaneous emphysema. The case was referred to the surgical team for emergency laparotomy for suspected perforated viscus. Clinically, her abdomen was distended but there was no sign of peritonism. In view of the high risk of perioperative morbidity and absence of peritonism, a CT scan was done to rule out the cause of pneumoperitoneum. CT scan showed bilateral pneumothorax, presence of air in the extra peritoneum and retroperitoneum. There was no air in the peritoneum and no evidence of perforated viscus. She was treated conservatively with bilateral chest tube insertion. Unfortunately, she developed multiorgan failure and succumbed to death.

Bilateral spontaneous pneumothorax in a non-intubated COVID-19 patient

Spontaneous bilateral pneumothorax is a rare condition occurring only in 1,3% of cases of spontaneous pneumothorax. Although spontaneous pneumothorax is recognized complication of COVID it is usually associated with severe cases of COVID pneumonia with massive lung involvement and a high level of inflammatory cytokines – so called "inflammatory storm". Large percentage of this patients requires life support with mechanical ventilation and pneumothorax is usually accompanied with pneumomediastinum. Nevertheless occurrence of spontaneous pneumothorax in non-intubated patients is very low. Therefore the presented case is exceptional in two ways – spontaneous pneumothorax occurred in non-intubated patient and is presented bilaterally. Early diagnosis of spontaneous bilateral pneumothorax can pose a diagnostic dilemma as it mimics progression of lung involvement in the course of COVID, pulmonary embolism or myocardial infarction. In our case apart from COVID pneumonia, patient had typical clinical presentation of myocardial infarction and known coronary artery disease, which initially mislead clinicians toward diagnosis of myocardial infarction (MI). However after exclusion of MI, chest radiograph was requested which revealed bilateral pneumothorax. The exact mechanism of pneumothorax development in non-intubated patients is not clear. Lung inflammation in COVID causes formation of pneumatocele, which can predispose to spontaneous pneumothorax. It is important to note that our patient developed pneumothorax without evident pneumatocele, underlying lung condition or history of trauma. This case shows that bilateral pneumothorax in COVID-19 can develop also in patients with only mild clinical course of COVID pneumonia. Early diagnosis and proper management is essential and can prevent life-threatening complications.

The Diagnosis of Unilateral Diaphragmatic Paralysis Using M-mode: A Case Report from Palestine

Background: Diaphragmatic paralysis is one the causes of dyspnoea and difficulty in breathing. There are many causes of diaphragmatic paralysis, especially trauma and iatrogenic injury of phrenic nerve. Usually, diaphragmatic paralysis diagnosis depends on fluoroscopic examination of diaphragmatic displacement during sharp sniffs. However, due to disadvantages of fluoroscopic examination, the trend for less radiation examination by using ultrasound is increasing especially using M-mode for detection of diaphragmatic motion during respiration. Case: A new-born baby boy with uneventful pregnancy and normal delivery with good general condition, developed severe respiratory distress at 3rd day of life and was diagnosed to have bilateral pneumothorax. Bilateral chest tubes were inserted with improvement of his condition. The baby then started to develop desaturation with serial chest x-rays done and showed elevated left hemi-diaphragm. Suspicion toward left hemi-diaphragm paralysis increased and due to his general condition, fluoroscopic examination was difficult. So that, Ultrasound with M-mode was used with diagnosis of the patient with left hemi-diaphragmatic paralysis. Conclusion: Ultrasound and the using of M-mode in detection of diaphragmatic motion is one of the most important and applicable diagnostic procedure for diagnosis of diaphragmatic weakness and paralysis.

Leriche Syndrome Diagnosed Due to Polytrauma: a Case Report

Background: Leriche syndrome is caused by atherosclerosis and is often characterized by symptoms such as intermittent claudication as well as numbness and coldness of the lower limbs. Its exact prevalence and incidence are unknown because it is a rare disease. We report a case of Leriche syndrome diagnosed incidentally on a trauma pan-scan computed tomography (CT).Case Presentation: A 61-year-old Asian man was driving a passenger car when he had a head-on collision with a dump truck and received an emergency call. He was transported to our hospital in a doctor's helicopter. Physical examination revealed the following vital signs: respiratory rate, 23 breaths per minute; SpO2, 98% under a 10 L administration mask; pulse rate, 133 beats per minute; blood pressure, 142/128 mmHg; Focused Assessment with Sonography for Trauma, positive; Glasgow Coma Scale E3V5M6; and body temperature, 35.9℃.Trauma pan-scan CT showed bilateral mandibular fractures, bilateral multiple rib fractures, bilateral pneumothorax, sternal fractures, peri-thoracic hematoma, small bowel perforation, mesenteric injury, right clavicle fracture, right ankle debridement injury, and thrombotic occlusion of the bilateral common iliac arteries from just above the abdominal aortic bifurcation. Although thrombotic occlusion needed to be differentiated from traumatic aortic injury, the presence of collateral blood vessels led to the diagnosis of Leriche syndrome, and conservative treatment was performed.Damage control surgery was required for small bowel injuries. From the second day of admission, the patient was treated with continuous intravenous heparin and prostaglandin preparations. However, impaired blood flow and reperfusion injury in the right lower extremity progressed. On the fifth day of admission, right thigh amputation was performed. The patient required renal replacement therapy for approximately two weeks starting from the third day of admission.Conclusions: In this case, conservative therapy was initially chosen as the treatment for Leriche syndrome. However, the complex factors in the acute phase of trauma lead to hemorrhagic necrosis development, resulting in amputation of the lower extremity. Our findings making necessitate the importance of decision of treatment indication and choice.