PNEUMOMEDIASTINUM

Question 1

Approach to the Critically Ill Pneumomediastinum

Answer 1

AIRWAY
Intubation rarely indicated

Avoid PPV

BREATHING
Assess for underlying associated condition: pneumothorax, COPD, Asthma, Pneumonia etc

Supplemental Oxygen not shown to improve time to resolution

Thoracostomy only if pneumothorax

Treat underlying cause (Asthma / COPD) as indicated

CIRCULATION
Assess for tension and
Needle / finger / tube thoracostomy i

Assess for pericardial fluid

EXPOSURE
Secondary survey if trauma

Question 2

History & Physical

Answer 2

Ask about:

Chest pain (76.6%)
Dyspnea (49.5%)
Cough (28%)
Neck Swelling (28%)
Neck Pain (26%)
Dysphagia (12%)
Odynophagia (11%)
Dysphonia (4%)

Trauma, Esophageal Instrumentation, Vomiting

Look for:
Crepitus (30-50%)
Hamman’s Sign (10-30%)
Pneumothorax (8.6%)

Question 3

Investigations

Answer 3

CT Chest: 100% sensitive

Esophogram with water-soluble contrast

Question 4

Treatment and Disposition:
Spontaneous
Trauma / Esophageal Injury

Answer 4

Spontaneous:
No treatment usually required.
Admission and Observation for 24-48 hrs.

Consider discharge with return to ED in 24-48 hrs for repeat CXR

Trauma / Esophageal Injury:
Further investigations / admission. Observation for 24-48 hrs.

ICU if HFNC, NIV, Mechanical Ventilation, hemodynamically unstable

Avoid PPV

Tube thoracostomy if pneumothoraces

Suppress cough