Morning Report: 3/19/2012

From the case files of Dr. Wendy Lau, Emergency Physician:

An 11 year old male with no significant past medical history presents with chest pain x 5 hours.  Patient states the pain started
suddenly while running in school.  The pain is sharp, mid-sternal, and worse on
inspiration.  The patient denies any sob, dizziness, or syncope.

On physical exam:

Vital signs are normal

General: Well appearing

Chest: lungs clear to auscultation bilaterally

You listen to the heart and hear the following:

What other parts of the physcial exam might be significant? What tests would you order to confirm the diagnosis?

Keep reading for further results. . .

 

 

 

 

 

Chest xray demonstrated radiolucent streaks tracking along
the margins of the heart, within the retrosternal space, and surrounding the
trachea.

When you re-examine the patient, crepitus is noted in right neck soft tissue

So, what is your diagnosis?

Keep reading for diagnosis and discussion. . .

 

 

 

 

 

Pneumomediastinum (PM): Free air contained within mediastinum – almost always originates from alveolar space or conducting airway.

Non-spontaneous PM – blunt/penetrating chest trauma, endobronchial or esophageal procedures, neonatal lung dz, mechanical vent, chest sx

Spontaneous PM

  • Increased alveolar pressures
  • Free air  tracks from ruptured alveoli along peribronchial vascular sheaths toward hilum of lung, then extends proximally within mediastinum; mediastium communicates with submandibular space, retropharyngeal space and vascular sheath within neck -> subq air in neck
  • Triggering factor identified in 70-90%
  • Vigorous cough – asthma cough being most common in children
  • Valsalva
  • Illicit drug ingestion
  • Inhalation of illicit drugs, chemical compounds, commercial aerosol i.e. huffing
  • Barotraumas – scuba diving/flying
  • Vigorous vomiting – Boerhaave syndrome (esophageal rupture)
  • Strenuous athletic activity, playing woodwind instruments

*Rarely leads to clinically significant complications
*Rarely tension pneumomediastinum -> decreased cardiac output – surgical emergency

Mortality variable based on underlying condition:

  • Boerhaave – 50-70% due to mediastinitis
  • Other high mortality etiologies  = Trauma – blunt or penetrating, trancheobronchial perforation
  • But spontaneous pm is usually self-limited and rarely produce significant symptoms

Presentation:

  • Chest pain
  • Dyspnea – may reflect asthma, tension pm
  • Dysphonia
  • Throat pain
  • Jaw pain

Workup:

  • ABG depending on clinical status
  • Cardiac enzymes
  • Toxicology
  • Chest xr
  • Chest CT if suspecting perforated esophagus or trauma

Procedures:

  • No chest tubes unless pneumothorax present
  • Bronchoscopy if suspecting tracheobroncial perforation
  • Esophagoscopy if suspecting Boerhaaves

Treatment:

  • Nitrogen washout with 100% O2 suggested
  • Analgesia

DC:

  • Observation?
  • No strenuous activity or forced expiration maneuvers until resolution

So, that’s the case. We’d like to hear your thoughts so post any comments below.

Thanks,

JK

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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1 comment for “Morning Report: 3/19/2012

  1. jwillis
    March 21, 2012 at 11:28 am

    Sounds like a spontaneous pneumomediatinum with the Hammond’s crunch on audio. As far as my experience these are conservatively managed with observation and repeat CXR. I’ve seen these patients get antibiotics for a possible injury but I do not think there is evidence for this. Other interesting history points from a quick literature search would to be ask about dental work (case studies about spontaneous pneumomediastinum from wisdom tooth extraction) and definitely about contact sports. No evidence based recommendation about when children (or adults) can return to contact sports after pneumomediastinum but should be addressed with the patient.

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