1. Boerhaave syndrome is a spontaneous rupture of the esophagus, classically presenting with retrosternal chest pain, recent vomiting, and subcutaneous emphysema. 2. CT and oesophagram are used to diagnose this condition, which has a high mortality if diagnosis is missed. 3. Management involves nothing by mouth, IV antibiotics, IV PPI, and either open surgical repair (gold standard) or esophageal stents if surgery is contraindicated.

1. Dan’s Soapbox 2

3. Case 1…
25 year old
Fit and well
Fell over pissed last night
Presents 14 hours post injury

4. Treatment options……
• Primary Repair
• Delayed Primary Repair
• Closure by secondary intent

5. When is too late for Primary Repair?
• The theory:
• A wound that is contaminated and colonised but doesn’t get the appropriate
management in the appropriate time frame allows further bacterial growth
and established infection, by which time closing the wound would not be
appropriate
• Appropriate management
• Thorough cleaning and closing
• Appropriate timeframe
• Talk of ‘golden period’
• Up to date …6 hours after that consider leaving wound open
• Others 12 hours

6. Delayed Primary repair
• The Theory
• Overtime (as part of the heeling process) there is increased wound blood flow,
recruitment of phagocytes, and therefore fighting of infection
• If on reviewing wound at a later date (?72 hours) if the wound doesn’t appear
infected then it would be suitable for closure
• The Reality
• Lack of evidence
• All evidence comes from infected surgical wounds (not studied in the ED setting)
• Organisation difficulties
• When
• Free of infection Vs already heeled
• Where
• Who

7. • Review of 418 studies
• One small study (19 delayed hand wounds) showed increased risk of
infection when > 12 hours to intervention
Conclusion: The existing evidence does not support the theory of a
golden period nor does it support the role of wound age on infection
rate in simple lacerations

8. Factors that increase risk of infection
• Age of patient
• Immunosupression – DM, renal failure etc
• Site (Face Vs Feet)
• Size and width
• Etiology (dog bites, foreign body, contamination, crush injuries)
• ?Time from injury

9. Case 1…
25 year old
Fit and well
Fell over pissed last night
Presents 14 hours post injury

10. What I will do….
• Get rid of thinking 6 / 12 / 18 hours is too late for primary repair
• Risk infection Vs cosmetic result
• Infection risk is related to multiple things
• time less important
• Involve patient in the discussion
• I can think of very few indications for delayed primary closure
• If employing primary closure (but think infection risk is high) consider
antibiotics or early follow up

11. IO Sizing

13. Insertion site
• Proximal Humerus
• Arm adducted and shoulder internally rotated
• Insertion site is most prominent aspect of greater tubercle
• 1 – 2 cm above surgical neck
• Proximal Tibia
• 2 cm medial to tibial tuberosity
• Distal Tibia
• 2 finger width proximal to most prominent aspect of the medial malleolus

14. • Enrolled 75 Obese patients
• Mean BMI 47.2
• Ultrasound to measure skin depth
• Results:
• If tibia was palpable (which it was in 70 / 75 patients)
• Blue needle sufficient
• Mean tissue depth humeral head is 29.6mm
• Yellow needle is required

15. IO Sizing

16. Case 2
• 48 year old women
• Fit and well
• Brought to ED with Chest pain and SOB by family members
• ECG

18. Thrombolysis
• Indication in arrest
• ALS guidelines
• ‘Fibrinolytic therapy should be considered when PE is suspected as a cause’
• Dose, duration, timing, method of administration unclear
• Dose in massive PE (not arrest)
• tPA 10mg IV bolus, 90mg over 2 hours

19. • Single centre, case series, retrospective study
• 23 patients PEA arrest (17 of these in the ED)
• 20 Massive PE confirmed on CTPA
• 17 known massive EP prior to arrest
• 3 post arrest
• 3 confirmed on Point of care ECHO
• Management
• 50mg tPA over 1 min (push dose)
• 2000 – 5000 IU heparin bolus + 10 IU/Kg hour infusion
• ALS treatment

20. The Results…..
• Patient cohort
• Oldish (72 + / - 5 years)
• Fatish (BMI 35 + / - 3)
• Thrombolysis time 6.5 minutes (+/- 2.1 min)
• ROSC in 22/23 patients mean time 2 – 15 mins
• No minor or major bleeding!
• At 22 month follow up
• 20 patients alive
• ‘return to before event functional capacity’
• Improvement in ECHO parameters

21. Improvement in ECHO parameters
Measurement time PASP (mmHg) RV/LV ratio
Admission 58.10 +/- 7.99 1.79 +/- 0.27
Within 48 hours 40.25 +/- 4.33 1.16 +/- 0.13
Follow up 22 months 32.40 +/- 4.67 0.93 +/- 0.16

22. What this adds…
• Small, single centre study with no control group / comparison
• Excellent outcomes (but time from arrest to thrombolysis is very
short)
• 50mg tPA push dose seems safe and effective and in an evidence
sparse area this should be our ‘go to’ in suspected / confirmed PE +
arrest

23. Case courtesy of Dr Maciej Mazgaj, Radiopaedia.org,
rID: 30376
CASE 3

24. Boerhaave Syndrome
• Classical features: retrosternal chest pain, recent vomiting, subcutaneous
emphysema
• High mortality (increases as diagnosis missed)
• Diagnosis
• CT
• Oesophagram
• Management
• NBM, IV abx, IV PPI
• Medical
• watch and wait. Abx, NBM
• Surgical
• Open repair is gold standard
• Oesohageal stents (if surgery contraindicated)