ESOPHAGEAL RUPTURE

Question 1

Approach to the Critical Patient with Esophageal Rupture

Answer 1

A - Stridor
B - RR 30, 02 sats 90% on Fi02 30%
PT AT RISK FOR PNEUMOTHORAX AND PLEURAL EFFUSION - MAY NEED TUBE THORACOSTOMY
C - Mottled appearance
D - GCS, PERRLA & check glucose
E - Exposure, take down dressings

Monitor
O2 Target to 94%
Vitals
IV Access: 2 large bore IV
Equipment for Airway and ECG

Vancomycin as a loading dose of 25-30 mg/kg IV plus piperacillin/tazobactam 3.375g IV

Immediately consult thoracic surgery for operative repair.

Question 2

DDx

Answer 2

Pulmonary embolism
Esophageal rupture/mediastinitis
Tamponade
Myocardial infarction
Aortic dissection
Pneumothorax

Esophageal Spasm
Esophagitis
Mallory-Weiss Tear

Question 3

Clinical Features: Iatrogenic

Answer 3

Retrosternal Chest Pain (70%)

Odynophagia

Dysphagia

Subcutaneous Emphysema

Recent h/o endoscopy

a/w

Fever (44%)

Dyspnea (26%)

Pneumomediastinum (19%)

Nausea / Vomiting (19%)

Question 4

Clinical Features: Boerhaave Syndrome (Mackler Triad) for spontaenous rupture

Answer 4

vomiting

followed by severe retrosternal chest pain (70%)

presence of subcutaneous emphysema

Only present in 50% of patients

a/w

Fever (44%)

Dyspnea (26%)

Pneumomediastinum (19%)

Nausea / Vomiting (19%)

Question 5

Risk Factors

Answer 5

Endoscopy
Severe vomiting / retching

Question 6

MCC

Answer 6

Iatrogenic (endoscopy)
Retching (Boerhaave Syndrome)

Question 7

Complications

Answer 7

Pneumothorax
Pleural Effusion
Sepsis

Question 8

Investigations

Answer 8

CBC
Comprehensive metabolic panel
Type and screen
Lactate
Blood cultures
Serum pH
BHcG

XRAY:
Lateral Neck
AP / lateral chest
Upright abdominal

CT or contrast esophagram with gastrografin

Question 9

Management

Answer 9

NPO

Hemodynamic Monitoring

Hydromorphone 0.2-0.4 mg sq q 15 min - 1 hr prn

Pantoloc 40 mg IV

Vancomycin as a loading dose of 25-30 mg/kg IV plus piperacillin/tazobactam 3.375g IV

Early Consultation with thoracic surgery

Consult ICU