How to manage tension gastrothorax: a case report of tension gastrothorax with multiple trauma due to traumatic diaphragmatic rupture
© The Author(s). 2017
Received: 6 December 2016
Accepted: 18 January 2017
Published: 26 January 2017
Tension gastrothorax is a kind of obstructive shock with prolapse and distention of the stomach into the thoracic cavity. Progressive gastric distension leads to mediastinal shift, reduced venous return, decreased cardiac output, and ultimately cardiac arrest. Therefore, it is crucial to decompress the stomach distension for the initial resuscitation of tension gastrothorax.
A 75-year-old female was transported to our resuscitation bay due to motor vehicle crash. At the time of arrival to our hospital, the patient developed cardiac arrest. While undergoing cardiopulmonary resuscitation, an unstable pelvic ring was recognized, so we performed a resuscitative thoracotomy to control hemorrhage and to perform direct cardiac massage. Once we performed the thoracotomy, the stomach and omentum prolapsed out of the thoracotomy site and through the diaphragm rupture site and spontaneous circulation was recovered. Neither the descending aorta nor the heart was collapsed. Although we had continued the treatment for severe pelvic fracture (including blood transufusions), the patient died. Given that (1) the stomach prolapsed out of the body at the time of the thoracotomy; (2) at the same timing, spontaneous circulation returned; and (3) the descending aorta and heart did not collapse, we hypothesized that the main cause of the initial cardiac arrest was tension gastrothorax.
Recognition of tension gastrothorax pathophysiology, which is a form of obstructive shock, makes it possible to manage this injury correctly.
The first description of tension gastrothorax was reported by Ordog et al. in 1984 . They described that a distended stomach in the thoracic cavity through the site of a diaphragm rupture can lead to mediastinum shift. Gastrothorax develops when increased intraabdominal pressure forces the stomach through an acquired or congenital defect in the diaphragm . Accumulation of gastric contents such as air, fluid and foods in the thoracic cavity raise intrathoracic pressure because the abnormally positioned and angulated gastroesophageal junction functions as a kind of one-way valve [2, 3]. This causes progressive mediastinal shift that can lead to respiratory failure, obstructive shock, and cardiac arrest, much like a tension pneumothorax. We report a case of tension gastrothorax which lead to cardiac arrest and introduce our algorithm for the management of tension gastrothorax.
A 75-year-old female pedestrian was hit by a motor vehicle. Examination by the emergency medical service crew found her heart rate 130/min, systolic blood pressure 84 mmHg, initial oxygen saturation 78% without supplemental oxygen. On the way to our hospital, an emergency physician got into the ambulance, established two intravenous lines and started fluid resuscitation. He noticed that her lung sounds were decreased on both sides.
Upon admission to our resuscitation bay, she had developed cardiac arrest but still breathed spontaneously. While undergoing cardiopulmonary resuscitation, we detected a pelvic fracture on palpation and found no fluid accumulation in the thoracic or abdominal cavities with ultrasound. We then performed a resuscitative thoracotomy in order to clamp the descending aorta and perform direct cardiac massage because we expected that the cause of cardiac arrest was bleeding from the severe pelvic fracture. At the time of the thoracotomy, the stomach and greater omentum prolapsed out of the body and spontaneous circulation was immediately recovered. We also found that the descending aorta and heart were not collapsed, and the heart was beating strongly. Although we were puzzled why the aorta and heart did not collapse despite the expected severe bleeding, we moved on to manage the pelvic fracture.
Despite treatment of the severe pelvic fracture with a pelvic C clamp, pelvic packing, and TAE, her hemodynamic instability continued. We considered that the persistent shock was caused by an injury other than pelvic fracture, so we decided to explore the abdominal and thoracic cavities because of the presence of the diaphragmatic injury. As we were unable to maintain adequate hemodynamics in spite of administering massive transfusion protocol and continuous epinephrine infusion, we introduced arterio-venous extracorporeal membrane oxygenation (ECMO). Under ECMO support, an emergency operation was performed with a two-pronged approach with a laparotomy and thoracotomy. Exploring the thoracic and abdominal cavities, we detected only the diaphragm rupture and prolapsed stomach. There was no other obvious intraabdominal organ or thoracic injury. We closed the diaphragm rupture site and chose an open abdominal management to avoid abdominal compartment syndrome. Despite these treatments, the patient died shortly after returning to the ICU. We think that the cause of death was a combination of hemorrhagic shock, traumatic coagulopathy, and post cardiac arrest syndrome caused by the tension gastrothorax.
Tension gastrothorax is considered as a sort of obstructive shock due to the distended stomach expanding into thoracic cavity. Five steps are necessary to develop a tension gastrothorax: (1) existence of a diaphragm defect, (2) increased intraabdominal pressure, (3) prolapse of the stomach into thoracic cavity, (4) a functional change in the gastroesophageal junction (by way of an abnormal angulation) to form a one-way valve, and (5) a reduction in cardiac output as a result of mediastinum shift [2, 3]. These steps might occur simultaneously or the prolapsed stomach might have already existed. This mechanism is similar in tension pneumothorax.
Review of tension gastrothorax 25 cases after traumatic injury
Number (% of all cases)
Recognition of tension gastrothorax pathophysiology, which is a form of obstructive shock, allows emergency and trauma physicians to manage this injury correctly.
NB drafted the manuscript. NB, SU, TT, YM, KM, HI, and KH were directly involved in patient care. All authors read and approved the final manuscript.
N. Bunya is a 10-year emergency physician at the Sapporo Medical University in Japan. K. Harada is a trauma surgeon of Advanced Critical Care and Emergency Center, Sapporo Medical University.
The authors declare that they have no competing interests.
Ethics approval and consent to participate
Because the patient has already died and she had no kin whom we could contact, we could not get written consent from her kin. Institutional review board of our facility (Sapporo Medical University) approved for reporting this case. Our research protocol number is 282–144.
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