Spontaneous Pneumomediastinum

    NextPrevious

    Spontaneous Pneumomediastinum

    Your patient is a 24 yo M with chest pain.  It is pleuritic. He has normal vitals and you’re not too concerned. You get a CXR and you see the result in this post. He has pneumomediastinum! What is that? What do I Do now?

    Spontaneous pneumomediastinum is rare, occurring in approximately 1 in 30,000 patients presenting to the ED. It typically presents with subcutaneous emphysema (MCC), sudden onset pleuritic chest pain, and dyspnea. Also, patients can develop neck pain, neck swelling, and hoarse voice. The heart exam may reveal a characteristic crunching sound that is synchronous with systole (Hamman’s sign)

    Causative mechanisms:

    It is most commonly described as resulting from positive pressure ventilation OR as a spontaneous occurrence caused by increased intrathoracic pressure. Esophageal perforation can lead to pneumomediastinum and subcutaneous emphysema, as can occur in Boerhaave’s syndrome. Rib fracture, neck trauma, and chest tube insertion have also been implicated in introducing air to the subcutaneous tissues through the respiratory tract. Infection with gas-forming organisms can also cause pneumomediastinum, but this is associated with mediastinitis. Air can also be introduced via the intra-abdominal or retroperitoneal gastrointestinal tract, as well. If air extends along the fascial planes of the submandibular and retropharyngeal spaces through the neural foramina into the epidural space, pneumoracchis (air within the spinal canal) can result.

    Identify the source:

    CT imaging (CT neck and CT chest with IV contrast), Bronchoscopy, EGD and esophagrams can be useful. An algorithm for the diagnosis and management of spontaneous pneumomediastinum from CHEST 2005 is available to help with difficult

    Clinical Significance:

    The clinical significance of subcutaneous emphysema ranges from benign to life threatening. The primary treatment is to treat the underlying cause. The symptoms often resolve within 1 week with oxygen therapy, reassurance, and analgesics. The majority of spontaneous subcutaneous emphysema cases resolve with conservative treatment, and certain cases may not even warrant admission to thehospital. Of note, subcutaneous emphysema with pneumomediastinum can occasionally lead to tension physiology is a life-threatening event that benefits from rapid decompression.

    • 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

    • Bag Mask Ventilation During Intubation

      A few days ago NEJM published the results of an investigation with profound implications for our specialty.  A group of intensivists and anesthesiologists conducted a multicenter, randomized trial conducted in seven ICUs to study theRead more

    • Gastric Emptying for Acute Poisonings

      At the request of department leadership, we will be revisiting methods of gastric decontamination for today’s pearl.  Two methods in particular. Ipecac-induced emesis and gastric lavage are two procedures that we read about in medicalRead more

    • Pacemakers Review pt. 3

      Today we will review complications associated w/ implanted pacemakers that you may encounter in the ED and thus ought to be familiar with. Generally, complications can be divided into two categories: early vs. late EarlyRead more

    • Pacemakers Review Pt. 2

      Cardiac pacing as an intervention can be conceptualized as addressing problems in electrophysiological conduction and/or.  So, for example, if there is a disruption in the electrical continuity between the atrium and the ventricle, a pacerRead more

    • Pacemakers Review Pt. 1

      The pursuit of mastery over cardiovascular emergencies demands a rough familiarity with implanted devices which includes why they get implanted in the first place (indications), how they work, how they malfunction, and how they affectRead more

    • In honor of a rosh review question that I got wrong, lets review Lyme disease!   Lyme disease is caused by the spirochete Boriella burgdorferi, transmitted to humans through tick bites from ixodes ticks. Location:Read more

    • NGT INSERTION

      Your patient has an SBO and has repeated bilious emesis on the side. The surgery team is in the OR and they ask if you can place the nasogastric tube (NGT). Lets review proper NGTRead more

    • No, that’s not an olive. That’s Pyloric Stenosis!

      Inspired by what appears to have been a very interesting day in the Peds ED, lets review a rare but interesting pediatric entity: PYLORIC STENOSIS Background: MC in Males (5:1) & firstborn children (30%) UsuallyRead more

    NextPrevious