Pneumomediastinum, pneumopericardium, and epidural pneumatosis in DKA

Pooyan, Payam; Puruckherr, Michael; Summers, Jeffrey A.; Byrd, Ryland P.; Roy, Thomas M.

doi:10.1016/s1056-8727(03)00059-x

Cited by 51 publications

(67 citation statements)

References 26 publications

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“…The average age for developing the complication is in the early 20 s. Young men likely have greater musculature and may thus create larger swings in alveolar pressure, leading to an increased risk of alveolar rupture. 11 Our patient was not muscular, and indeed had a BMI at the lower end of normal.…”

Section: Pneumomediastinum In Dkamentioning

confidence: 57%

Diabetic ketoacidosis due to fulminant type 1 diabetes: A rare subtype of type 1 diabetes leading to unusual sequelae

Lane

Champion

Orde

et al. 2014

Journal of the Intensive Care Society

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Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes (T1D), which without treatment leads to death. Fulminant type 1 diabetes (FT1D) is a subtype characterised by a markedly rapid and almost complete destruction of pancreatic b-cells, with acute onset leading to severe metabolic derangement and commonly ICU admission. We present a case of an 18-year-old male presenting with FT1D with two rare complications of pneumomediastinum and stress-induced cardiomyopathy (SIC) with significant myocardial necrosis. We also discuss the aetiology of the pneumomediastinum; the latest thoughts on SIC: moving beyond the simple description of 'Takotsubo cardiomyopathy'; the role of troponins in critical illness; and genetic predisposition for DKA due to FT1D. KeywordsFulminant type 1 diabetes, pneumomediastinum, stress induced cardiomyopathy, troponin, Takotsubo cardiomyopathy Case reportAn 18-year-old Filipino male presented to the Emergency Department with a three-day history of lethargy, vomiting, tachypnoea and increasing drowsiness. There was no known past medical history, nor any history of polyuria, polydipsia or weight loss. On initial examination, his vital signs were as follows: heart rate 130 beats/min; blood pressure 105/ 48 mmHg; respiratory rate 24 breaths/min; oxygen saturation 90% on 6 L oxygen/min; temperature 34.0 C, GCS 8/15 (E1M5V2). He also demonstrated voluntary guarding on abdominal palpation and neck stiffness. He had thin body habitus without central adiposity (BMI 20.6 kg/m 2 ). His arterial blood gas showed pH 7.13; PaO2 7.46 kPa; PaCO2 3.6 kPa; HCO3-9 mmol/L; BE À20 mmol/L; glucose 50 mmol/L and lactate 5 mmol/L. He was diagnosed with DKA due to new onset T1D and treated with intravenous fluids and a fixed-rate insulin infusion.Subsequent laboratory analysis of the patient's blood showed urea 32.6 mmol/L; creatinine 379 mmol/L; glucose 107.3 mmol/L; anion gap 45 mmol/L and ketones 7.1 mmol/L. The serum lipase was not elevated. An initial ECG showed sinus tachycardia with no other acute changes. Due to his altered level of consciousness, he received a CT scan of his brain, which was unremarkable, and a lumber puncture which showed a high glucose but no other abnormalities. His conscious level and blood pressure decreased and he was intubated, ventilated, commenced on a noradrenaline infusion and transferred to the ICU for further management.His initial ECG on arrival to the ICU showed ST elevation in leads II, III and aVF with right bundle branch block (Figure 1). Immediate transthoracic echocardiography (TTE) showed global left ventricular (LV) hypokinesis with apical akinesis/dyskinesis (Figures 2(a) to (c) and 3) with the ejection fraction estimated at 15% and severely reduced right ventricular (RV) systolic function. His high-sensitivity troponin, which was retrospectively found to be

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Section: Pneumomediastinum In Dkamentioning

confidence: 57%

Diabetic ketoacidosis due to fulminant type 1 diabetes: A rare subtype of type 1 diabetes leading to unusual sequelae

Lane

Champion

Orde

et al. 2014

Journal of the Intensive Care Society

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“…The exact pathophysiology is unknown; however, it is believed that Kussmaul respiration leads to a significant 20–30 mm Hg rise in intra-alveolar pressure and this may result in alveolar rupture 5. Furthermore, vomiting can predispose to alveolar rupture through increasing intrathoracic pressure 5. More recently, alveolar histological changes and fibrosis have been described as part of the ‘diabetic lung’ in patients with poorly controlled diabetes 6.…”

Section: Discussionmentioning

confidence: 99%

“…Epidural pneumatosis is the presence of air in the epidural space and has been reported following trauma, strenuous exercise, lumbar puncture and epidural analgesia 5. Epidural pneumatosis complicating spontaneous PM is rare, and results from the posterior dissection of the PM through the intervertebral space into the epidural canal 4.…”

Section: Discussionmentioning

confidence: 99%

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Epidural pneumatosis associated with spontaneous pneumomediastinum: a rare complication of diabetic ketoacidosis

et al. 2016

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Pneumomediastinum and epidural pneumatosis are rare complications of diabetic ketoacidosis (DKA). These result from the emesis and hyperventilation associated with DKA which lead to alveolar rupture and air escape into the mediastinal and epidural spaces. These complications are often asymptomatic and resolve with the correction of the underlying metabolic abnormality. Oesophageal contrast studies are only required if oesophageal perforation is suspected in patients presenting with persistent vomiting and chest pain. We report the rare association of pneumomediastinum and epidural pneumatosis complicating DKA in a 19-year-old female patient.

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“…In Case 2, the aetiology of the patient's extracranial epidural emphysema is owing to pneumomediastinum from barotraumas induced by hyperpnoea or severe vomiting from diabetic ketoacidosis. Diabetic ketoacidosis is a rare cause of pneumomediastinum and therefore a rarer cause of extracranial epidural emphysema; however, the actual incidence of pneumomediastinum complicating diabetic ketoacidosis is unknown [13,14].…”

Section: Discussionmentioning

confidence: 99%

Extracranial epidural emphysema: pathway, aetiology, diagnosis and management

Cloran¹,

Bui-Mansfield²

2011

BJR

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ABSTRACT. Extracranial epidural emphysema is an uncommon phenomenon that refers to the presence of gas within the epidural space. As an isolated finding, it is typically benign, but it can be a secondary sign of more ominous disease processes, such as pneumothorax, pneumoperitoneum and epidural abscess. Although the phenomenon has been cited in case reports, a comprehensive review of this topic is lacking in the radiology literature. The authors' aim is to report our experience with extracranial epidural emphysema, illustrating the spectrum of its clinical presentation. We also review the aetiology, pathophysiology, diagnosis and management of extracranial epidural emphysema. Pneumorrhachis (also known as aerorachia) is a term that has been used to describe air within the spinal canal. It can be separated into two distinct entities, epidural and intradural. In general, the presence of intradural intraspinal air has been associated with significant morbidity, while the presence of epidural air is typically more benign [1]. Epidural air within the spinal canal is best descriptively termed extracranial epidural emphysema and has been described sporadically in case reports. The purpose of this pictorial review is to present a diversity of clinical scenarios that can give rise to extracranial epidural emphysema and to discuss its pathophysiology, diagnosis and management. Methods and materialsA comprehensive literature search was conducted on the MEDLINE database using PubMed. Keywords including pneumorrhachis, pneumosaccus, aerorachia, intraspinal pneumocele, pneumomyelogram, epidural emphysema and epidural pneumatosis were used in the literature search. In addition to a review of the literature, four cases of extracranial epidural emphysema collected at our institution are also reported. They illustrate the common pathways of extracranial epidural emphysema.All the clinical records were reviewed for demographic data, symptoms and duration of symptoms. The study did not require approval from the institution's Investigation Review Board. However, the Brooke Army Medical Center Department of Clinical Investigation reviewed and approved the manuscript for publication. Results Case 1A 59-year-old male complained of left flank pain. He had a non-contrast CT of the abdomen and pelvis that showed a left ureterovesical junction stone. The examination also revealed severe degenerative disc disease at L4-5 and L5-S1 disc spaces with vacuum disc phenomenon and extracranial epidural emphysema behind the L5 vertebral body (Figure 1a,b). Case 2A 20-year-old male presented with diabetic ketoacidosis and crepitus in the neck and upper chest. He had palpable crepitus over his jaw and a friction rub on cardiac examination. A CT scan of the chest showed severe pneumomediastinum tracking from the mediastinum into the soft tissues of the neck, anterior and posterior chest wall with pneumopericardium and extracranial epidural emphysema (Figure 2a,b). Case 3A 49-year-old male with Crohn's disease presented with abdominal pain and distensi...

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Pneumomediastinum, pneumopericardium, and epidural pneumatosis in DKA

Cited by 51 publications

References 26 publications

Diabetic ketoacidosis due to fulminant type 1 diabetes: A rare subtype of type 1 diabetes leading to unusual sequelae

Diabetic ketoacidosis due to fulminant type 1 diabetes: A rare subtype of type 1 diabetes leading to unusual sequelae

Epidural pneumatosis associated with spontaneous pneumomediastinum: a rare complication of diabetic ketoacidosis

Extracranial epidural emphysema: pathway, aetiology, diagnosis and management

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