34 yo wm with no reported T 98.7 P 105 BP 148/90 chronic medical problems presents with complain of O2 98% RR 18 “sharp” chest pain x 2 hours that he initially noticed Gen: WDWN, anxious following crack cocaine use CV: Tachycardic, RR, no the morning of presentation. His pain is ongoing, worse m/r/g with deep inspiration. He has no associated Pulm: Lungs CTA bilat, dyspnea/diaphoresis and chest wall without denies recent cough/congestion/fevers or crepitus chills. At presentation he is Extr: no cy/cl/ed; awake/alert without respiratory dispress. appropriate pulses/cr. Abd: s/nt/nd – normal bs.
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.
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 Hammonds 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
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.
This additional cervical spine radiograph shows airwithin the prevertebral soft tissues