Chest Case #8

34 yo wm with no reported chronic medical problems presents with complain of “sharp” chest pain x 2 hours that he initially noticed following crack cocaine use the morning of presentation. His pain is ongoing, worse with deep inspiration. He has no associated dyspnea/diaphoresis and denies recent cough/congestion/fevers or chills. At presentation he is awake/alert without respiratory dispress.

History and PhysicalT 98.7 P 105 BP

148/90 O2 98% RR 18

Gen: WDWN, anxious

CV: Tachycardic, RR, no m/r/g

Pulm: Lungs CTA bilat, chest wall without crepitus

Extr: no cy/cl/ed; appropriate pulses/cr.

Abd: s/nt/nd – normal bs.

Chest X-Ray

Diagnosis: Pneumomediastinum

1. The PA view shows a thin layer of air is adjacent to the left and right heart borders and the fine white line of the raised parietal pleura. Air outlines the lateral margin of the descending aorta and tracks into the soft tissues of the superior mediastinum and base of the neck.

2. On the lateral view, a thin layer of air outlines the ascending and descending aorta

Oxygen IV Fluids Further Studies

Chest CT can be helpful if etiology is traumatic. Gastrografin swallow if patient has recent history of

endoscopy or violent nausea/vomiting Disposition

Admission is typically required for esophageal tear, traumautic etiology, or patients at risk for serious complications

The clinical course of isolated spontaneous pneumomediastinum from intraparenchymal alveolar rupture is relatively benign and disposition can be determined based on clinical picture /expected course.

ED Management

Etiology There are three potential sources of mediastinal air: the

esophagus, the tracheobronchial tree, and the lung. Physical exam

On physical examination, cardiac auscultation may reveal a crunching or cracking sound synchronous with cardiac contractions, known as Hammond's sign.

Air that has migrated into the subcutaneous tissues of the neck and chest wall causes palpable crepitus and swelling, which may be considerable.

Complications Although rare, tension pneumomediastinum is a life

threatening complication that is diagnosed clinically. Mediastinitis is more common in patients with esophageal

tear

Pearls

Presentation Patients with pneumomediastinum presents with chest pain in 90% of

cases, dyspnea in 50% of cases, and occasionally neck pain or dysphagia.

Antecedent vomiting or recent endoscopy should raise concern for esophageal perforation.

Alveolar hyperinflation and subsequent rupture with air tracking is the most common etiology of pneumomediastinum (the macklin effect) Forceful inhalation with breath-holding (crack cocaine / marijuana

use) Blunt traumatic injury to the chest Positive pressure ventilation Rapid ascent in scuba diving

Follow up Patients should avoid strenuous physical activity, scuba diving,

weight lifting until resolution of symptoms, for up to 6 months.

Pearls

Additional Images

This additional cervical spine radiograph shows air within the prevertebral soft tissues