Laryngotracheal separation with pneumopericardium after a blunt trauma to the neck.

Case report On the 14 April 1998 a 27 year old male motorcyclist was involved in a road traYc accident in the early hours of the morning, when he hit a bus and went underneath it. He was found to be slightly confused at the scene of the accident and was complaining of pain in the front of his neck. He was breathing spontaneously. On arrival to the accident and emergency (A&E) department in Grimsby at 0600 he was fully conscious and orientated and had a Glasgow Coma Score of 15/15. He was breathing spontaneously with tachypnoea (45 per minute). The airway was clear. His pulse rate was 92 per minute and blood pressure was 160\104 mm Hg. He had a 3 cm long laceration over his chin. There was normal air entry on both sides on his chest. There were no signs of head injury or any other associated injuries. He arrived with a hard collar around his neck and was given oxygen 10 litres per minute and using a facemask and intravenous fluids were given. His oxygen saturation remained at 80% despite giving oxygen. After arrival to A&E the patient became more agitated and oxygen saturation had decreased to 79% and he developed obvious surgical emphysema in the neck. Endotracheal intubation with rapid sequence induction was considered, however, pre-oxygenation has failed to improve his oxygen saturation; in fact it deteriorated to 75%. It was impossible to visualise the laryngeal opening with failure to intubate the patient; the airway was almost completely obstructed. Cricothyroidotomy and mini-tracheostomy were attempted but failed to establish any airway. A tracheostomy incision was performed but the trachea was not identified and there was gross swelling and surgical emphysema in the soft tissue of the neck. The patient’s condition deteriorated and he soon arrested. Cardiopulmonary resuscitation was started immediately. Radiological examination of the neck revealed the presence of air in the soft tissue planes with an increased prevertebral soft tissue space over the maximum normal of 5 mm opposite the third cervical vertebral body (figs 1 and 2). The chest radiograph showed air in the mediastinum (pneumomediastinum) and in the pericardial sac (pneumopercardium) (fig 3). Pericardiocentesis was performed: 50 ml of blood and 300 ml