Pneumomediastinum without pneumothorax caused by esophageal rupture

The Hidden Tear: Improving Diagnostic Accuracy for Spontaneous Esophageal Perforation in the ED

Esophageal perforation is a serious medical condition characterized by a tear or hole in the muscular layer. This case report details the presentation, diagnosis, and treatment of a patient with missed esophageal perforation at an emergency department. The report highlights treatment options, missed findings from the chest X-ray, and relevant case details. Management primarily depends on prompt detection and intervention through conservative measures or surgical repair. Identifying the issue within the initial hours after presentation can significantly decrease the mortality rate, which can be as high as 30%.

[Thorax injuries]

Thorax injuries may be divided etiologically into blunt and penetrating types, depending on the nature of the insult. In European practice, the former predominates by far, and in only about 5% of cases thoracotomy provides the necessary thorax drainage. Morbidity in this type of injury typically involves concomitant lung contusion, sometimes with fatal acute respiratory distress syndrome. In these cases, special ventilation forms, optimal reduction of pain, and organ replacement are the decisive therapeutic methods. In contrast, about 80% of penetrating trauma to the thorax require prompt transpleural or trans-sternal surgery, depending on the type of injury. Emergency first aid must follow the principle of "scoop and run". Each minute elapsed until emergent thoracotomy can be decisive to survival in these cases, and the fastest possible transport from the place of injury takes priority over time-consuming stabilization.

Factors affecting outcome in penetrating oesophageal trauma

Background

Penetrating oesophageal trauma is rare and the risk factors affecting outcome have not been clearly identified. Delayed management has been cited as a factor contributing to the high rates of morbidity and mortality, but evidence for this is lacking.

Methods

A retrospective study was undertaken of patients with penetrating oesophageal trauma presenting to a level I trauma centre over 8 years. Outcome was assessed in terms of mortality, morbidity (oesophageal and non-oesophageal), and length of hospital and intensive care unit (ICU) stays.

Results

Fifty-two patients with oesophageal injury who reached the operating theatre were included. The overall mortality rate was 6 per cent. Fifteen patients (29 per cent) developed oesophageal injury-related complications. Time from injury to management was the only important risk factor for the development of oesophageal complications (P = 0·001), but did not affect the length of ICU (P = 0·560) or hospital (P = 0·329) stay, incidence of non-oesophageal injury-related complications (P = 0·963) or death (P = 0·937). Patients with gunshot injuries spent longer in the ICU (P = 0·007) and the duration of hospital stay was longer for those with higher-grade oesophageal injuries (P = 0·025).

Conclusion

The risk of oesophageal injury-related complications was directly related to the interval between the trauma and definitive management of the oesophageal injury.

Imaging of chest trauma: radiological patterns of injury and diagnostic algorithms

In patients after chest trauma, imaging plays a key role for both, the primary diagnostic work-up, and the secondary assessment of potential treatment. Despite its well-known limitations, the anteroposterior chest radiograph remains the starting point of the imaging work-up. Adjunctive imaging with computed tomography, that recently is increasingly often performed on multidetector computed tomography units, adds essential information not readily available on the conventional radiograph. This allows better definition of trauma-associated thoracic injuries not only in acute traumatic aortic injury, but also in pulmonary, tracheobronchial, cardiac, diaphragmal, and thoracic skeletal injuries. This article reviews common radiographic findings in patients after chest trauma, shows typical imaging features resulting from thoracic injury, presents imaging algorithms, and recalls to the reader less common but clinically relevant entities encountered in patients after thoracic trauma.