Empyema is a well recognised complication of pneumonia.1 We report a case of pulseless electrical activity (PEA) treated in the emergency department (ED) with intercostal tube drainage based on clinical findings, where a tension empyema was found to be the cause. To our knowledge, this is the first report of actual cardiac arrest from this cause.
- PEA, pulseless electrical activity
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A 42 year old man was admitted to the emergency department by ambulance. The paramedic crew had found him in respiratory distress. En route to hospital, he deteriorated to cardiorespiratory arrest. Basic life support was immediately instituted. He had significant previous medical history of type I diabetes mellitus and trisomy 21.
His first recorded cardiac rhythm in the resuscitation room was bradycardic pulseless electrical activity (PEA). His airway was secured by endotracheal intubation, and advanced life support protocols were followed, including intravenous epinephrine and atropine. Clinical assessment of the chest revealed a hypoinflated left hemithorax with absent breath sounds, and intubation of the right main bronchus was suspected. The endotracheal tube was withdrawn, but this did not change the clinical findings. Further examination found the trachea to be central and the left hemithorax dull to percussion. A clinical diagnosis of fluid in the left hemithorax was made.
Presuming a haemothorax, a closed needle aspiration of the left chest was attempted using a 14 gauge intravenous cannula and 50 ml syringe in the second intercostal space in the midclavicular line. This revealed a small amount of yellow watery aspirate with no air present. Immediately following this procedure, a left lateral incision was made in the fifth intercostal space along the anterior axillary line in order to insert an intercostal drain. On blunt dissection through the pleura, approximately 500 ml of malodorous pus was released under pressure, followed by an immediate return of spontaneous circulation, with a sinus tachycardia on the cardiac monitor. A central pulse was palpable, and a blood pressure of 120/50 mmHg was recorded. A 32 Fr intercostal drain was inserted and secured, which continued to drain a further 400 mls of pus over the next 30 minutes (fig 1), although air was not expelled. The patient was further stabilised and transferred to the intensive therapy unit. Unfortunately, he developed multisystem organ failure and coagulopathy and died 20 hours after admission. A postmortem examination was not carried out, and microbiological samples taken failed to identify any organism.
In all cases of cardiac arrest, potentially reversible causes should be considered.2 In this case, it was clinically apparent that there was a problem ventilating the left lung. This was not resolved by repositioning the endotracheal tube, and was not clinically a tension pneumothorax. Drainage was carried out on clinical findings, with immediate effect.
There have been several reports published of tension pyopneumothorax3–5 often associated with gastro-oesophageal fistulae, but to our knowledge, this is the first case of cardiac arrest attributed to a tension effect purely from an empyema. The differential diagnoses for this arrest included sepsis and hypoxia, although these could not explain the return of circulation immediately following drainage.
Empyema is defined as an opaque fluid in the pleural space, with the cloudiness due to neutrophils and/or organisms.6 It is a well recognised complication of pneumonia, affecting 2–5% of patients with pneumococcal pneumonia.1 Of direct relevance to this case, both mental handicap and diabetes mellitus have been listed as independent risk factors for the development of empyema by the Empyema Subcommittee of the Research Committee of the British Thoracic Society.6
The most common presenting feature is malaise, with cough, dyspnoea, pain, and fever also being well recognised. Diagnosis is by aspiration; however, suggestive features on chest radiograph, computed tomography, and ultrasound have been described. Causative organisms can be gram positive or negative, anaerobic or fungal, and in 25% of cases are mixed (such as Strepococcus milleri plus anaerobes.) Treatment options include combining antibiotics with diagnostic aspiration, repeated aspiration and intercostal tube drainage, or surgical treatment such as rib resection or decortication. One multicentre study has suggested surgical management to be the preferred option.6
This case is, to our knowledge, the first documenting cardiac arrest due to a tension empyema and the subsequent acute management. It highlights the importance of searching for reversible causes of cardiac arrest, and describes the use of the intercostal drain as part of resuscitation of a non-traumatic cardiac arrest.
Competing interests: none declared