You are working in the critical care area and need to log a trauma resuscitation since this is your last chance to get certified! A 65 year old male is brought by EMS for shortness of breath. He is tachypneic to 30, speaking in short phrases, has a blood pressure of 95/60, is tachycardic to 120, with saturation of 92% on room air. Finally, he has a rectal temp of 100.8!
OK then, you made the decision that he is septic. Now where does the infection come from? As you perform your exam you put him on oxygen and a monitor, and place an IV and draw the labs.
The medical interview reveals a history of prostate cancer for which he is undergoing treatment. He tells you he has pleuretic chest pain, shortness of breath, and cough worsening for a 2-3 days.
He is retracting and has decreased breath sounds on the right side.
Wait a minute. What the hell does this have to do with Trauma?! You can’t log it. Is this case about an obvious pneumonia? Or at most a PE? Don’t even start telling me this is a post about STEMI! Don’t worry, wait. It might still be a trauma case. At very least, you will be traumatized if it is not!
So you start some fluid — gently until you know what is going on with the heart — start antibiotics, and talk to him to calm him down. After your interventions his EKG is sinus tachycardia at a rate of 110, BP is 100/60 and O2 sat is 98 — but he is still retracting! At long last his portable chest x ray is uploaded:
You view the image and want to look smart in front of your junior so you read a right side pneumothorax with lung collapse and a right pleural effusion. It’s not a trauma resuscitation but at least you can log a chest tube!
You rapidly set up for the chest tube. Everything goes well until your pop into the plural space and hear the beautiful “woosh” sound of air, but suddenly you smell the worst stink of your life! While inserting the tube a gray-brown smelly fluid flows out and all non-essential personnel flee the resus bay. The patient apologizes, “Sorry doc, smells like I pooped, I never lost control before, sorry!”
So you have a complicated pneumonia with empyema? Probably. You send 600cc of the effluvium to the lab and test for everything you can think of. After that you order a repeat chest X ray.
Great, Your chest tube is in and the lung expanded. The patient looks better clinically and you feel fantastic! Labs start trickling in with a WBC of 35,000 and mild metabolic acidosis. The pleural fluid Gram stain is positive for mixed bacteria. What could this stinky fluid be! Surgery is already on board, the patient has a chest tube, and MICU is aware. You are about to admit to MICU with cardiothoracic surgery consult as PENDING.
Then you sit and ponder deep thoughts. You don’t want to miss anything about any patient. Your thoughts return to the basic differential diagnosis for chest pain from Tintinalli:
Chapter 48: Chest Pain
“Life-threatening concerns in acute chest pain are acute coronary syndrome, aortic dissection, pulmonary embolism, pneumonia, tension pneumothorax, and esophageal rupture …”
And suddenly something clicks. Esophageal rupture? You remember the stink and the patient’s voice echoes in your brain, “Sorry doc, I pooped.”
The patient needs a CT scan of the chest before you admit him. Your surgical and MICU consultants discuss whether to perform a Pulmonary CTA or chest CT. In a blazing flash of glory you recommend oral contrast with the chest CT! Of course, water soluble contrast, not barium. Your patient drinks it only 15 minutes before the scan and you get the picture below:
Now the story is different! You broaden your antibiotic coverage and admit the patient to SICU. At the end of your shift, like every other shift, you want to read a bit about the case you had today:
You read from Chapter 77 of Tintinalli, also here and here:
the most common cause of esophageal perforation is Iatrogenic; after that it is spontaneous perforation resulting from ulcers and vomiting. Other causes are Caustic ingestion, food impaction, difficult intubation and finally, penetrating and blunt trauma!
Two third of cases caused by trauma are delayed in diagnosis, only presenting with delayed complications just like your patient. The mortality is 20%!
The symptoms include chest pain and difficulty swallowing. Subcutaneous emphysema and widened mediastinum (food and air leaks into mediastinum) develop if the perforation is at the upper level. Pneumothorax and pleural effusion (food and air leaks into pleural space) occur in perforations of the lower esophagus … just like your patient!
Your diagnostic modalities were correct; either CT or X Ray with PO contrast is diagnostic.
You conclude that this might be a trauma case! Of course you did not get a comprehensive history. Go back to your patient and ask about recent vomiting, endoscopy, and trauma. Your patient might have fallen from a 3 story building last week!
In that case, log your trauma resuscitation. Congratulation, you saved a life and you are not traumatized!
Think about esophageal perforation when the patient has chest pain. Consider it more seriously when there is mediastinal widening, pneumopericardium, subcutaneous emphysema, or pneumothorax with pleural effusion, especially when the fluid contains food (there is a case report of milk in an infant!) or if it stinks, like feces! Patient can present with severe sepsis.
Early esophageal rupture may be very difficult to diagnose. Those caused by trauma may be missed and try not to Mistake perforation for acute myocardial infarction and pulmonary embolism!