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EMGuideWire's Radiology Reading Room: Pneumomediastinum

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Pneumomediastinum
Chelsea Wilson, MD & Jacob Leedekerken, MD
Department of Emergency Medicine
Carolinas Medical Center & L...

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Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Prog...

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Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental ed...

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EMGuideWire's Radiology Reading Room: Pneumomediastinum

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pneumomediastinum and is brought to you by Jacob Leedekerken, MD and Chelsea Wilson, MD.

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pneumomediastinum and is brought to you by Jacob Leedekerken, MD and Chelsea Wilson, MD.

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EMGuideWire's Radiology Reading Room: Pneumomediastinum

  1. 1. Pneumomediastinum Chelsea Wilson, MD & Jacob Leedekerken, MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Charlotte, North Carolina Michael Gibbs, MD, Faculty Editor The Chest X-Ray Mastery Project
  2. 2. Disclosures  This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center.  The goal is to promote widespread mastery of CXR interpretation.  There is no personal health information [PHI] within, and all ages have been changed to protect patient confidentiality.
  3. 3. Process • Many are providing clinical cases and presentations are then shared with all contributors on our departmental educational website. • Contributors from many Carolinas Medical Center departments, and now… Brazil, Chile, and Tanzania. • We will review a series of CXR case studies and discuss an approach to the diagnoses at hand: pneumomediastinum.
  4. 4. Visit Our Website www.EMGuidewire.com For a complete archive of Chest X-Ray presentations and much more!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. It’s All About The Anatomy!
  7. 7. Definition Extraluminal gas within mediastinum often originating from lungs, trachea, central bronchi, esophagus, and/or peritoneal cavity. Symptoms  Chest Pain (55%)  Dyspnea (40%)  Cough (32%)  Neck Pain (17%)  Odynophagia (14%)  Dysphagia (10%) Signs  SQ Emphysema (30-90%)  Hamman’s Crunch (12-50%)  Dyspnea (30-60%) Pneumomediastinum - Background
  8. 8. Pneumomediastinum - Imaging Nguyen, J and Lee, M. “A Case of the Incidentally Discovered Pneumomediastinum.” Imaging Choice  Lateral soft tissue neck – most sensitive of the diagnostic x-rays  CT – helps define the full extend of disease Imaging Signs  Free air along mediastinum  Subcutaneous air in neck/shoulders  Continuous diaphragm sign (air below heart)  Naclerio V Sign (well demarcated “V” along left heart border & diaphragm)  Air along great vessels/heart border
  9. 9. Continuous Diaphragm Sign Naclerio V Sign
  10. 10. 2° Iatrogenic 2° Medical & Traumatic Spontaneous  Endoscopic procedures  Intubation  Pleural instrumentation  Central vascular procedure  Chest/abdominal surgery  Blunt chest injury  Penetrating chest injury  Asthma/COPD  Bronchiectasis  Interstitial lung disease  Thoracic malignancy  Tobacco use  Recreational drugs  Breath holding  Weightlifting Vasileios K. Journal of Thoracic Disease 2015; 7:S44-S49. Management Essentials  Manage the underlying cause  Pain management & cough suppression as indicated  Oxygen may increase gas absorption in severe cases  Brief period of observation vs. close outpatient follow-up  If concern for esophageal source -> esophagram, broad spectrum antibiotics, admission, and surgical consult Pneumomediastinum – Causes & Management
  11. 11. Conclusions Spontaneous pneumomediastinum: • A benign condition seen primarily in younger adults that is associated with an uneventful recovery and unlikely recurrence • In most cases the presentation involves chest pain, dyspnea, cough, and/or subcutaneous emphysema • The diagnosis requires a high index of suspicion because 30% of patients present without any precipitating factors and 30% of patients will have a normal initial chest X-ray
  12. 12. Conclusions Secondary pneumomediastinum, that had a 39% mortality in this study, is associated with: • An older age at presentation • A higher prevalence of associated pneumothorax • A higher requirement for tube thoracostomy drainage • The presence of a pleural effusion • Longer hospital stays
  13. 13. Patient #1 52-year-old admitted with dyspnea, fever, cough. He was initially started on non-invasive ventilation but worsened and required endotracheal intubation. Post-intubation reveal consolidation and pneumomediastinum [Fig 1a]. He improved with supportive care. Patient #2 68-year-old admitted with dyspnea requiring increasing CPAP support. Following intubation imaging reveals pneumomediastinum with widespread extension. He did develop a pneumothorax requiring drainage. He subsequently improved with complete resolution. Patient #3 66-year-old requiring admission and early intubation. Chest X-ray revealed extensive pneumomediastinum. Serial CXR confirmed gradual resolution.
  14. 14. Discussion • In the patient with COVID-19, pneumomediastinum appears to be the consequence of the high PEEP required to maintain oxygenation. • In this case series all patient had gradual resolution of their pneumomediastinum. • While the patient is intubated, serial chest X-rays are recommended to monitor for the possibility of iatrogenic pneumothorax.
  15. 15. Carolinas Medical Center Case Studies
  16. 16. Case #1 Gunshot Wound To The Neck. Injury To The Trachea & Esophagus.
  17. 17. Injury To The Trachea & Esophagus. Case #1 Gunshot Wound To The Neck.
  18. 18. Case #1 Gunshot Wound To The Neck.
  19. 19. Pneumomediastinum Case #1 Gunshot Wound To The Neck.
  20. 20. Case #1 Gunshot Wound To The Neck.
  21. 21. Pneumomediastinum Pneumomediastinum Pneumomediastinum Case #1 Gunshot Wound To The Neck.
  22. 22. Case #2: 13-Year-Old With Throat And Chest Pain.
  23. 23. Case #2: 13-Year-Old With Throat And Chest Pain. Pneumomediastinum & Pneumopericardium
  24. 24. Pneumomediastinum & Pneumopericardium Case #2: 13-Year-Old With Throat And Chest Pain.
  25. 25. Pneumomediastinum & Pneumopericardium Case #2: 13-Year-Old With Throat And Chest Pain.
  26. 26. Case #3: Young Male With Intractable Vomiting.
  27. 27. Pneumomediastinum & Pneumopericardium Case #3: Young Male With Intractable Vomiting.
  28. 28. Case #3: Young Male With Intractable Vomiting.
  29. 29. Pneumomediastinum & Pneumopericardium Case #3: Young Male With Intractable Vomiting.
  30. 30. Case #4: 25-Year Old With Repeated Episodes Of Vomiting.
  31. 31. Pneumomediastinum Case #4: 25-Year Old With Repeated Episodes Of Vomiting.
  32. 32. Case #4: 25-Year Old With Repeated Episodes Of Vomiting. Pneumomediastinum
  33. 33. If you have an interesting case of pneumomediastinum, we to send a set of digital PDF images and a brief descriptive clinical history to: michael.gibbs@atriumhealth.org Your de-identified case(s) will be posted on our education website and you and your institution will be recognized!

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