Case 1

HPI: 8 y/o male return to ED for abd pain recheck. Child was initially seen in ED the day before, referred by PMD for r/o appy. Pt also c/o dry cough, runny nose, congestion, sore throat & pleuritic CP. Child still c/o persistent vague peri-umbilical pain w/ some anorexia, but tolerates liquids

PE: Vs T 102.3, P 92, R 20, BP 100/52, 96% sat on RA

Gen: non toxic appearing child

HEENT: oropharynx normal, TMs clear, moist mucous membranes

Neck: supple

CV: RRR

Resp: CTAB, no W/C

Abd: soft, mild subjective tenderness around umbilicus, no G/R/M, good BS, no McBurney’s sign

Skin: well hydrated

ED Course: Since the child was still symptomatic & no w/u was done at his first visit, we decided to hydrate w/ IVF and run some blood tests. His CBC, Comp Chem & urine dip were all normal. Pt tolerated PO fluids in the ED, and was ready for d/c. The nurse then came up to you and reported that the child’s still c/o CP so an X-ray was ordered to r/o pneumonia (PNA).

What’s your reading?

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Answer: The CXR shows air in the soft tissue around the RUL.

The patient was admitted. F/U films showed progression of the sub-Q emphysema to the neck.

F/U CXRs also showed progression of the pneumomediastinum.

Discussion

Spontaneous pneumomediastinum is an infrequent condition, most commonly affecting young males. The condition is usually precipitated by valsalva maneuvers, bronchospasm, physical exertion & inhalation drug use. Retrospective case series by Abolnik in Chest (July 1991) & Panacek in Ann Emerg Med (Oct 1992) reported that the most common presenting complaints were chest pain & dyspnea. Other complaints included neck pain/swelling & dysphagia. The classic Hamman’s sign were usually appreciated retrospectively, after the Dx was made on CXR. Admission is usually indicated for serial exams. An esophogram may be indicated if Boerhaave's syndrome is suspected. Bronchoscopy may also be indicated if the patient’s condition worsens. Prophylactic Abx is often given, although no data support its use. These pts, including the one in this case, often will have a benign clinical course and no intervention is usually needed.

I brought up this case for two important points, other than the fact that it was an interesting case. First, do not get tunnel vision when you’re evaluating pts sent from PMDs for specific rule-outs. This patient was sent over for a r/o appy. Second, there’s more to a CXR than the lung fields. I use the following mnemonics when evaluating trauma CXRs, but found that it’s also useful for all CXRs.

Mnemonic for evaluating CXR – AABCDEFG

A: airway – deviated?

A: aorta – mediastinum widened?

B: bones – rib or thoracic spine fxs? remember that most rib fxs tend to be lateral

C: cardiac – enlarged heart? water-bottle heart c/w pericardial effusion?

D: diaphragm – air under diaphragm? stomach bubble above diaphragm?

E: emphysema – soft tissue, mediastinum?

F: fluids – effusion? hemothorax?

G: gastric tube – in stomach under diaphragm? or right bronchus?