Tension viscerothorax ensuing blunt abdominal trauma: a case report

Tension viscerothorax is an infrequent but potentially deadly complication of traumatic diaphragmatic rupture. Abdominal organ herniation into the thoracic cavity results in increased intrathoracic pressure, thus mimicking a tension pneumothorax with subsequent physiological derangements. A 15-year-old female was medevacked to our hospital after sustaining significant blunt thoracoabdominal trauma secondary to a high-speed Motor vehicle crash (MVC). On arrival the patient was hemodynamically unstable and hypoxic despite being endotracheal intubation (ETT) intubated with ongoing bag valve mask (BVM) ventilation. A left thoracostomy was emergently performed, oxygen saturations improved momentarily thereafter. Exam revealed a prominent seatbelt sign and left thoracoabdominal bruising with abrasions. Computer tomography (CT) of the chest, abdomen and pelvis revealed a left traumatic diaphragmatic rupture, left hemothorax with mediastinal shift, grade 2 splenic laceration, grade 3 left kidney laceration, grade 2 left liver lobe laceration, grade 1–2 pancreatic injury, and an unstable L1-L2 flexion injury concerning for possible spinal cord injury, along with a comminuted left scapular fracture. The patient was taken for an emergent left anterior thoracotomy, revealing omentum, stomach, and spleen within the left thoracic cavity obscuring the diaphragmatic injury. A midline laparotomy was performed, to allow visualization and repair of the diaphragm which revealed transected jejunum. A temporary abdominal closure system was placed. Two days later she returned for washout with anastomosis. The patient ultimately underwent additional orthopedic surgeries, along with a prolonged hospitalization including rehabilitation but was ultimately discharged home. Tension viscerothorax must be considered in children who sustain severe blunt thoracoabdominal trauma, as it can cause life-threatening physiological derangements.