Rosen & Barkin's 5-Minute Emergency Medicine Consult (108 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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See Also (Topic, Algorithm, Electronic Media Element)
  • Facial Fractures
  • Globe Rupture
  • Iritis
  • Oculomotor Nerve Palsy
  • Periorbital and Orbital Cellulitis
CODES
ICD9
  • 376.52 Enophthalmos due to trauma or surgery
  • 802.6 Closed fracture of orbital floor (blow-out)
  • 802.7 Open fracture of orbital floor (blow-out)
ICD10
  • H05.429 Enophthalmos due to trauma or surgery, unspecified eye
  • S02.3XXA Fracture of orbital floor, init encntr for closed fracture
  • S02.3XXB Fracture of orbital floor, init encntr for open fracture
BOERHAAVE SYNDROME
Lauren M. Smith
•
Edwin R. Malone
BASICS
DESCRIPTION
  • Spontaneous esophageal rupture from sudden combined increase in intra-abdominal pressure and negative intrathoracic pressure
    • Causes complete, full-thickness (transmural), longitudinal tear in esophagus
  • Esophagus has no serosal layer (which normally contains collagen and elastic fibers):
    • Results in weak structure vulnerable to perforation and mediastinal contamination
    • Esophageal wall is further weakened by conditions that damage mucosa (i.e., esophagitis is of various causes).
  • Majority of perforations occur at left posterolateral wall of the lower third esophagus.
  • Significant morbidity/mortality (most lethal GI tract perforation):
    • Owing to explosive nature of tear
    • Owing to almost immediate contamination of mediastinum with contents of esophagus
    • Overall mortality can approach 20%
    • Mortality can double if treatment is delayed >24 hr from rupture
    • Cervical rupture associated with the lowest mortality, followed by abdominal and thoracic rupture, respectively
ETIOLOGY
  • Associated with:
    • Forceful vomiting and retching (most common)
    • Heavy lifting
    • Seizures
    • Childbirth
    • Blunt trauma
    • Induced emesis
    • Caustic ingestions
    • Laughing
    • History of Barrett ulcer
    • History of HIV/AIDS
    • History of pill esophagitis
  • Common in middle-aged men
  • Medical procedures cause over 50% of all perforations.
Pediatric Considerations
  • Described in female neonates but rarely seen
  • Consider caustic ingestions
DIAGNOSIS
SIGNS AND SYMPTOMS
History
  • Often no classic symptoms
  • Most common symptoms:
    • Chest or epigastric pain after vomiting/retching
  • Mackler triad:
    • Vomiting/retching
    • Chest pain
    • Subcutaneous emphysema
  • Retrosternal chest pain present in most patients:
    • Often pleuritic
    • Radiates to back or left shoulder
    • Worsens with swallowing
  • Odynophagia
  • Swallowing may precipitate coughing
  • Frequently, a history of alcoholism or heavy alcohol ingestion may be elicited
ALERT

The vague nature of symptoms often lead to a delay in outcome and poorer prognosis

Physical-Exam
  • Dyspnea
  • Diaphoresis
  • Subcutaneous emphysema in neck and chest wall
  • Mediastinal crackling on auscultation (Hamman crunch)
  • Pleural effusions
  • Tachypnea
  • Fever
  • Shock, in more severe cases
  • If untreated, mediastinitis will develop and abscesses will form.
  • Not usually associated with bleeding
ESSENTIAL WORKUP
  • Upright chest radiographs (preferably posteroanterior and lateral views if tolerated) evaluating for:
    • Pneumomediastinum
    • SC emphysema
    • Pleural effusion (left side)
    • Pneumothorax
    • Widened mediastinum
    • Hydropneumothorax
    • Empyema
    • Free peritoneal air
    • Naclerio “V” sign:
      • V-shaped radiolucency seen through the heart (air in left lower mediastinum)
  • Contrast esophagram identifies leak in esophagus:
    • Aids in decision of which type of surgical approach
    • Controversy exists regarding contrast use, water-soluble vs. barium
    • Water-soluble contrast material was thought to be less toxic if extravasated into the mediastinum; however, if aspirated may cause necrotizing pneumonitis and has a higher rate of false negatives
    • Barium, more sensitive for diagnosing perforation, but more irritating to the mediastinum
    • If esophagus is intact, use barium contrast for better detail
DIAGNOSIS TESTS & NTERPRETATION
Lab
  • CBC
  • PT/PTT/INR
  • Blood cultures
  • Pleural effusion:
    • Amylase content
    • pH (<6)
    • Undigested food particles
  • ECG
Imaging
  • CXR
  • Endoscopy:
    • Controversial because this may extend perforation and/or introduce air into mediastinum
  • CT chest:
    • Sensitive for identifying free air, periesophageal fluid, mediastinal widening, air or fluid in pleural spaces; however, does not isolate lesion
    • Indicated if esophagram cannot be obtained
    • Evaluates other intrathoracic structures
DIFFERENTIAL DIAGNOSIS
  • Cholecystitis
  • Dissecting aortic aneurysm
  • Intestinal obstruction
  • Lung abscess
  • Mesenteric thrombosis
  • Myocardial infarction
  • Pneumothorax
  • Pericarditis
  • Pneumonia
  • Pancreatitis
  • Pulmonary thromboembolism
  • Ruptured abdominal viscus
  • Spontaneous pneumomediastinum (clinically benign)
TREATMENT
PRE HOSPITAL
  • Airway control must be established if patient unresponsive or airway patency in jeopardy.
  • Establish 2 large-bore intravenous catheters and treat hypotension with 0.9% NS.
  • Avoid opiates until patient is in ED to avoid complication of hypotension.
INITIAL STABILIZATION/THERAPY
  • ABCs
  • Airway control: 100% oxygen or intubate patient if unresponsive or airway patency is in jeopardy.
  • Establish intravenous access and treat hypotension:
    • Administer 1 L (20 mL/kg) bolus with 0.9% NS (or lactated Ringer solution).
    • Initiate dopamine if blood pressure does not respond to fluids.
    • Central catheter placement if condition of patient remains unstable for more efficient delivery of fluids and monitoring of central venous pressure
ED TREATMENT/PROCEDURES
  • NPO
  • Careful placement of a nasogastric tube to decompress the stomach
  • Bladder catheter to monitor urine output
  • Expedient diagnosis to decrease incidence of morbidity/mortality
  • Prompt surgical consultation
  • Definitive treatment:
    • Surgical repair
    • Endoscopic stent placement, considered in appropriate patients
    • Conservative management, may be considered in patients with a contained perforation
  • Initiate broad-spectrum antibiotics directed against oral microflora and gastrointestinal pathogens:
    • Ampicillin/sulbactam + gentamicin
    • Imipenem/Cilastatin
MEDICATION
  • Ampicillin/sulbactam: 3 g IV q6h
  • Dopamine: 2–20 μg/kg/min IV per bolus
  • Gentamicin: 2 mg/kg load, then 1.7 mg/kg IV q8h or 5–7 mg/kg IV QD (assuming normal renal function)
  • Imipenem/cilastatin: 250–500 IV q6h

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