CURRENT Essentials of Critical Care.pdf

164 Current Essentials of Critical Care■■■Boerhaave SyndromeEssentials of Diagnosis• Esophageal perforation leading to suppurative mediastinitis• History of excessive or rapid alcohol or food ingestion• Vomiting or retching followed by severe, typically left sidedchest pain; exacerbated by respiration and swallowing• Dyspnea can be prominent feature• Fever, hypotension, tachycardia, tachypnea• Subcutaneous emphysema, Hamman crunch• Leukocytosis and elevated serum amylase• Radiographic findings: pneumomediastinum, pneumopericardium,pneumothorax, pleural effusion, subcutaneous emphysema• Esophagogram with water-soluble contrast material has 75%sensitivity; consider repeating if negative• CT scan of chest helpful if esophagogram negative• Pleural fluid demonstrates low pH and high amylase; may detectfood particlesDifferential Diagnosis• Aortic dissection • Pulmonary embolism• Myocardial infarction • Spontaneous pneumothorax• Perforated peptic ulcer • Pancreatitis• Iatrogenic esophageal ruptureTreatment• Immediate broad-spectrum antibiotics• Supportive measures including aggressive hydration with isotoniccrystalloid• Restrict all oral intake• Total parenteral nutrition to support nutritional status• Nasogastric intubation with suctioning• Aggressive and early surgical treatment• Rare patients may recover with conservative therapy and pleuraldrainage only■ PearlFactors predicting a poor outcome in Boerhaave syndrome includespontaneous perforation and a greater than 24 hour delay in diagnosisand initiation of treatment.ReferenceJanjua KJ: Boerhaave’s syndrome. Postgrad Med J 1997;73:265. [PMID:9196697]