A ‘normal’ chest Xray

    NextPrevious

    A ‘normal’ chest Xray

    What do you see when you take a look at this Chest radiograph? It isn’t immediately noticeable (and was read as normal), and is a good reminder of why you should always check your own films, and why a systematic read is important.  If all you were looking for was “r/o PNA/PTX” you could easily miss the subcutaneous air, as well as the subtle border around the cardiac silhouette which should raise you concern for atraumatic pneumomediastinum.

    This is a relatively uncommon diagnosis which often presents with: chest pain, dyspnea, and cough. Physical exam is often unremarkable, though subcutaneous emphysema can occasionally cause crepitus. Substantial air can also cause Hamman’s Sign (a crunching, rasping sound, synchronous with the heartbeat).

    Most often, pneumomediastinum is a sequelae of asthma. Alevolar ruptures during asthma attacks can cause air leaks which can leak into the mediastinum (one that is contiguous with the pleural space would cause both pneumothorax and pneumomediastinum). These cases are often self limited, and can be treated conservatively with rest and analgesics (there are rare cases of asthma-induced pneumomediastinum progressing to tension pneumomediastinum; the literature on this phenomenon is sparse with barely more than a dozen reported cases)

    The dreaded and most severe cause of pneumomediastinum, however, is Boerhaave Syndrome, or esophageal rupture. This is a critical diagnosis that must not be missed; a water-soluble (ie, not barium) swallow study is the diagnostic test of choice. If clinical suspicion is high, be sure to have prophylactic antibiotics administered while awaiting confirmatory testing.

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • renal handling of water

      If you were on a tea & toast diet, how much water would you need to drink before you develop hyponatremia? I haven’t seen anyone work out the numbers before so here are my calculations. AndRead more

    • acute acidemia physiology

      As alluded to in the first post, don’t be fooled by a “normal” potassium in the setting of DKA because osmotic diuresis and H+/K+ exchange means that total body potassium is actually LOW. You all knowRead more

    • renal handling of potassium

      the first symptom of hyperkalemia is death Earlier post covered temporizing measures to counter hyperkalemia — namely, intracellular shift, increasing cardiac myocyte threshold potential. Give furosemide if the patient still urinates and consider dialysis, but then askRead more

    • bicarbonate revisited

      Previous post reviewed the safety of balanced crystalloids in hyper K. But what was up with serum bicarbonate decreasing with saline administration? This post introduces a new way of looking at the anion gap to possiblyRead more

    • hyperkalemia and balanced crystalloids

      Is it safe to give LR or plasmalyte to a hyperkalemic patient (these balanced crystalloids have 4-5 mEq/L K as opposed to 0 mEq/L K in normal saline)? Postponing the discussion of renal handling of potassium toRead more

    • hyperkalemia physiology

      You’ll likely encounter hyperkalemia on your next Resus / Cardiac shift, and you’ll instinctively treat it. But take a moment to review the fascinating physiology behind the “cocktail”! First, consider how K+ is buffered byRead more

    • Slow down your tachycardia (but not really)

      You’re sitting in resus bemoaning the departure of your most beloved attending when suddenly a patient wheels in without warning. The patient looks relatively stable but the triage RN tells you her heart rate wasRead more

    • Otitis externa: use the ear wick!

      Acute otitis externa (AOE) is a common complaint seen in pediatric as well as adult emergency departments. AOE is typically not accompanied by acute otitis media, although concurrent cases are possible. Also called “swimmer’s ear”Read more

    NextPrevious