1. A 34-year-old man presents with ongoing chest pain worse with deep inspiration following crack cocaine use that morning. 2. On exam, he is tachycardic but without respiratory distress. Lungs are clear to auscultation bilaterally without crepitus. 3. Chest x-ray shows a thin layer of air outlining the heart borders, aorta, and tracking into the superior mediastinum and neck, consistent with pneumomediastinum.

1.  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.

3. 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

4.  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.

5.  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

6.  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.

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