Event from Call

[camkiss]

1:45am: phone rings while on call, "We need you in the ER stat!". This is never good, as our community hospital private practice ER guys manage airways and do a great job.
I walk into the room and two ER docs are looking at a chest x-ray. I glance at the x-ray and then the patient. He is a 30-something sitting up in bed diaphoretic and tachypneic. Sats are 98% on 3L NC. I glance at the x-ray as the other docs look at me. Patient has subcutaneous emphysema in his neck and chest. Apparently just prior he was eating Doritos and choked on one and began vomiting. He then noticed his mouth swelling and began having trouble breathing.
I do an exam: crepitus throughout neck, chest. Patient opens his mouth and his soft tissue fills the space. If there was a MP score worse than 4, this would be it. Every time he coughs, you can see the air expanding. Neck anatomy is somewhat obscured by sub q air.
What is your diagnosis and plan?

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[Chloroform4Life]

1:45am: phone rings while on call, "We need you in the ER stat!". This is never good, as our community hospital private practice ER guys manage airways and do a great job.
I walk into the room and two ER docs are looking at a chest x-ray. I glance at the x-ray and then the patient. He is a 30-something sitting up in bed diaphoretic and tachypneic. Sats are 98% on 3L NC. I glance at the x-ray as the other docs look at me. Patient has subcutaneous emphysema in his neck and chest. Apparently just prior he was eating Doritos and choked on one and began vomiting. He then noticed his mouth swelling and began having trouble breathing.
I do an exam: crepitus throughout neck, chest. Patient opens his mouth and his soft tissue fills the space. If there was a MP score worse than 4, this would be it. Every time he coughs, you can see the air expanding. Neck anatomy is somewhat obscured by sub q air.
What is your diagnosis and plan?

Tracheal tear from doritos. Swelling may be from venous obstruction in pts neck from compression by ptx or subcutaneous air. Consider hereditary angioedema or ACEi angioedema as well.

Prep neck, topicalize nose, neck, superior laryngeal nerve, trachea with lidocaine. Awake nasal fineroptic with awake trach/crich as back up plan. Use small ett 6.0-6.5. Maintain spont respiration. Make sure no ptx on chest x ray. Consult ENT. If ENT can be immediately available, have them come to bedside and be ready for surgical airway while you do nasal fiberoptic.

Easy peasy

 

[btbam]

Easy peezy when the pt has crepitus throughout the neck?

 

[Chloroform4Life]

Well....coming up with the appropriate plan is easy peasy....executing said plan would take considerable skills....which is why an anesthesiologist was called, and not someone like.......a crna.

 

[Robotic Wis-Hipple]

A 6-6.5 ETT via nasal route is fairly likely to not be long enough depending on how far into the trachea you're hoping to get. MLT tube is made for this if you have any your scope will get thru.

This is a classic maintain spontaneous respirations, topicalize, awake sitting fob intubation in the OR with neck prepped and surgeon ready scenario.

 

[urge]

Trach. Call ENT.

 

[Robotic Wis-Hipple]

What if no ENT in house or close?

 

[pjl]

What if no ENT in house or close?

Whip out Netter on phone. Toss to EM physician, knowing that you may be more qualified to perform a surgical airway than them. One of my partners ended up doing a slash Trach in a slightly different scenario with two EM trained docs stepping back. Apparently the "if this fails we need to do a trach immediately" meant "if I can't get the airway, hand me a scalpel and watch me do a trach from across the room." He was super cordial with the ED guys afterwards because he is a better man than me.

If no ENT, General surgery would be appropriate, if they can get there quickly.

 

[Noyac]

Take him to the OR with ENT standing ( at bedside not in the hallway) by prepped and draped.
The issues I see here are many. Apparently, every time he coughs the SQ emphysema increases. So how do you keep this guy from coughing? You can't do a transtracheal injection because of the anatomy most likely and it makes them cough. I don't know if there is time for nebs but that rarely works as well in my hands. I like the nasal FOB approach. I would use a nasal RAE 7.0. I feel like the smaller tubes have issues but I'd have a 6.0 ready as well. You don't want any nasal bleeding either. Good topicalization and vasoconstriction is a must. Have the guy sitting upright and cooperative. Consider a remi infusion ( to control the coughing but be aware of the resp depression obviously) and possibly precedex.
Once you see cords spray with 4% lido and give it a second if you can. Then pass thru and spray some more. It doesn't matter as much now if he coughs because you are in. Slide the tube in.
Go change your scrubs.

 

[Urzuz]

Tracheal tear from doritos. Swelling may be from venous obstruction in pts neck from compression by ptx or subcutaneous air. Consider hereditary angioedema or ACEi angioedema as well.

Prep neck, topicalize nose, neck, superior laryngeal nerve, trachea with lidocaine. Awake nasal fineroptic with awake trach/crich as back up plan. Use small ett 6.0-6.5. Maintain spont respiration. Make sure no ptx on chest x ray. Consult ENT. If ENT can be immediately available, have them come to bedside and be ready for surgical airway while you do nasal fiberoptic.

Easy peasy

Just a small point, this likely isn't a tracheal tear at all. This is a condition called Boerhaave's syndrome, which is characterized by coughing/retching/vomiting leading to a esophageal tear. The kid likely gagged on his Doritos, and because he's presumably a young muscular dude, he was coughing/retching with such force that it tore his esophagus.

 

[camkiss]

All good comments. ENT is not in house and is a solid 30-45 minutes away.

 

[Robotic Wis-Hipple]

It doesn't sound like this is a wait 30-45min scenario. So, trauma/gen surg stat page to OR while you transport with neb lido (may get some benefit), +\- glyco based on HR, if you have lido paste give him the lollipop but I'd probably wait to do any even minor airway instrumentation until entering the OR with a FOB ready and surgeon in the room with a tray out. Even phenylephrine nasal spray before some topicalization may make him sneeze/cough so I'd try to have neb and more directed local applied first. I'm not needling the neck so have to rely on inhaled and gently applied oral application of topicalization (benzocaine vs lido lollipop, I don't see this guys mouth opening/anatomy doing well trying to place lido pledgets with Krause forceps). This dudes neck doesn't sound like a straightforward slash trach so obviously try to avoid but be ready for it if it comes to that.

 

[Chloroform4Life]

Just a small point, the tracheal tear that the patient has is unlikely from the Doritos themselves. This is a condition called Boerhaave's syndrome, which is characterized by coughing/retching/vomiting leading to a tracheal tear. The kid likely gagged on his Doritos, and because he's presumably a young muscular dude, he was coughing/retching with such force that it tore his esophagus.

Just a small point ..... the trachea and the esophagus are two different tubes.

 

[Noyac]

If no surgery specialty available then this guy could meet his maker sooner than later. If Gen Surg present then I'm thinking you are his best chance. At least that's how it is at my facility. They are good but may not be able to pull this save off.
I'd consider using the US to locate the trachea. If it's not that deep I would put and 18g angiocath in it for entraining o2. Or jet ventilation. This can buy some much needed time. And it tells the person where to cut if needed.
If this guy tore his esophagus this badly he is likely not going to survive anyway.

 

[Urzuz]

Just a small point ..... the trachea and the esophagus are two different tubes.

You're right, I meant to say esophageal tear. Will go back an edit my post. Regardless, common things being common, this likely isn't a tracheal tear resulting from Doritos like you first hypothesized.

Maybe you should hit the books instead of being a smart ass...you might learn something.

 

[deleted171991]

If no surgery specialty available then this guy could meet his maker sooner than later. If Gen Surg present then I'm thinking you are his best chance. At least that's how it is at my facility. They are good but may not be able to pull this save off.
I'd consider using the US to locate the trachea. If it's not that deep I would put and 18g angiocath in it for entraining o2. Or jet ventilation. This can buy some much needed time. And it tells the person where to cut if needed.
If this guy tore his esophagus this badly he is likely not going to survive anyway.

I think this is the one best thing anybody could do in a difficult airway situation. Get a long angiocath through the cryc in the airway, guard it with your life. In the worst case scenario, even an anesthesiologist can put a wire in it, then slash the membrane vertically around it, then finger, bougie etc. (Not that I ever had to do that.)

 

[caligas]

Trach. Call ENT.

Awake trach, right?

 

[urge]

All good comments. ENT is not in house and is a solid 30-45 minutes away.

Either Gen surg, EM, or you will have to go MacGyver on the guy's neck. Good luck.

 

[urge]

Awake trach, right?

Not even lidocaine.

I kid. Maybe the amount of lido in a TB syringe.

 

[caligas]

Not even lidocaine.

I kid. Maybe the amount of lido in a TB syringe.

Yes.

My question is whether to mess around with awake FOI or just go straight to awake trach.

 

[urge]

Yes.

My question is whether to mess around with awake FOI or just go straight to awake trach.

He will cough quite a bit with an awake FOB. I'm afraid of that doing more harm.

 

[chocomorsel]

Just a small point, this likely isn't a tracheal tear at all. This is a condition called Boerhaave's syndrome, which is characterized by coughing/retching/vomiting leading to a esophageal tear. The kid likely gagged on his Doritos, and because he's presumably a young muscular dude, he was coughing/retching with such force that it tore his esophagus.

Ok, maybe, but where is all the sub q emphysema coming from?

 

[caligas]

He will cough quite a bit with an awake FOB. I'm afraid of that doing more harm.

I agree.

 

[Noyac]

Ok, maybe, but where is all the sub q emphysema coming from?

I'm wondering if it COULD be a tracheal tear.

 

[Chloroform4Life]

You're right, I meant to say esophageal tear. Will go back an edit my post. Regardless, common things being common, this likely isn't a tracheal tear resulting from Doritos like you first hypothesized.

Maybe you should hit the books instead of being a smart ass...you might learn something.

But I like being a smart-ass. And I have been hitting the books pretty hard recently.....

I know what Boerhaave's is. This patient's presentation just did not sound like Boerhaave's so I still think tracheal tear is the more likely diagnosis.

 

[deleted162650]

But I like being a smart-ass. And I have been hitting the books pretty hard recently.....

I know what Boerhaave's is. This patient's presentation just did not sound like Boerhaave's so I still think tracheal tear is the more likely diagnosis.

Last I checked, those 2 structures sit pretty close to each other. A tear in one does not exclude a tear in the other. I'm counting down the days until I hear about Doritos getting slapped with a major lawsuit for selling unsafe razor sharp trachea lacerating tortilla triangles.

 

[camkiss]

Our hospital does not have surgeons in house, and this patient was likely not going to last 30-45 minutes to have one called in.
This is how I managed it:
I believed this was Boerhaave, but I was also concerned for tracheal injury. ER doc and I agreed to have trach kit standing by as well as an angiocath. I did a ketamine and versed induction to maintain spontaneous ventilation. I gently slid the glidescope blade into his mouth and confirmed I could find the cords. The entire mouth, posterior pharynx, epiglottis, and cords were edematous, but I could see them. I withdrew the scope and gave succinylcholine, reinserted the Glidescope and tubed him. Ventilation through the tube did not seem to worsen the sub q emphysema, so we were fairly certain at that point it was an esophageal injury (or that the injury was proximal to the ETT cuff, if tracheal). When the sux wore off I gave him a vial of vecuronium to prevent any further coughing, a propofol gtt, and a helicopter ride to a tertiary care facility.

 

[Robotic Wis-Hipple]

How much Ketamine and how much versed? I'd guess a pretty good dose of K for him to tolerate a glide look without going nuts.

I like the moxie but not sure I'd take on the orals with that plan. But of course, we've all had patients that on paper tell you to go one way but once eyes on you decide you can be more aggressive, sounds like your assessment was correct.

Good job working with what you have, I'm sure that will be one of my first lessons once I get out, not all centers have anesthesia techs and FOBs ready to come running lol. If there's one thing I haven't gotten to do many of its an awake glide/DL.

 

[pgg]

Nice case, thanks for posting it, well done.

 

[Urzuz]

Ok, maybe, but where is all the sub q emphysema coming from?

But I like being a smart-ass. And I have been hitting the books pretty hard recently.....

I know what Boerhaave's is. This patient's presentation just did not sound like Boerhaave's so I still think tracheal tear is the more likely diagnosis.

Straight from UpToDate for you guys:

"Effort rupture of the esophagus, or Boerhaave syndrome, is a spontaneous perforation of the esophagus that results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure (eg, severe straining or vomiting)."

"The clinical features of Boerhaave syndrome depend upon the location of the perforation (cervical, intrathoracic, or intra-abdominal), the degree of leakage, and the time elapsed since the injury occurred. Patients with Boerhaave syndrome often present with excruciating retrosternal chest pain due to an intrathoracic esophageal perforation. Although a history of severe retching and vomiting preceding the onset of pain has classically been associated with Boerhaave syndrome, approximately 25 to 45 percent of patients have no history of vomiting [9]. Patients may have crepitus on palpation of the chest wall due to subcutaneous emphysema. In patients with mediastinal emphysema, mediastinal crackling with each heartbeat may be heard on auscultation especially if the patient is in the left lateral decubitus position (Hamman's sign). However, these signs require at least an hour to develop after an esophageal perforation and even then are present in only a small proportion of patients [4]. Within hours of the perforation, patients can develop odynophagia, dyspnea, and sepsis and have fever, tachypnea, tachycardia, cyanosis, and hypotension on physical examination. A pleural effusion may also be detected"

How does this presentation not sound like Boerhaave's?

Edit: And to answer your question regarding where the subcutaneous emphysema comes from, the esophageal tear in Boerhaave's is a full thickness tear, as opposed to a Mallory-Weiss tear. Therefore, air is able to spread through the subcutaneous tissues following the tear with all the retching the patient is having.

Whether or not this is Boerhaave's syndrome is one thing, but as far as I'm concerned it is a fairly classic presentation as evidenced by the above.

 

[ranvier]

Great case and nice job. Thanks for posting it to share. Awake glidescope is a great tool. I have the sux drawn up and in line....if I can see I have someone push it.

 

[confusingleaf]

Our hospital does not have surgeons in house, and this patient was likely not going to last 30-45 minutes to have one called in.
This is how I managed it:
I believed this was Boerhaave, but I was also concerned for tracheal injury. ER doc and I agreed to have trach kit standing by as well as an angiocath. I did a ketamine and versed induction to maintain spontaneous ventilation. I gently slid the glidescope blade into his mouth and confirmed I could find the cords. The entire mouth, posterior pharynx, epiglottis, and cords were edematous, but I could see them. I withdrew the scope and gave succinylcholine, reinserted the Glidescope and tubed him. Ventilation through the tube did not seem to worsen the sub q emphysema, so we were fairly certain at that point it was an esophageal injury (or that the injury was proximal to the ETT cuff, if tracheal). When the sux wore off I gave him a vial of vecuronium to prevent any further coughing, a propofol gtt, and a helicopter ride to a tertiary care facility.

thanks for posting. great job. how was your sphincter tone?

 

[chocomorsel]

Thanks. I wasn't questioning if it was Borhaves syndrome. Just that I didn't know where the air came from. As in something was missing for a complete picture and tracheal injury made sense.

The stomach. Now I know.
I always learn something on this website. Spend way too much time on it.

Straight from UpToDate for you guys:

"Effort rupture of the esophagus, or Boerhaave syndrome, is a spontaneous perforation of the esophagus that results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure (eg, severe straining or vomiting)."

"The clinical features of Boerhaave syndrome depend upon the location of the perforation (cervical, intrathoracic, or intra-abdominal), the degree of leakage, and the time elapsed since the injury occurred. Patients with Boerhaave syndrome often present with excruciating retrosternal chest pain due to an intrathoracic esophageal perforation. Although a history of severe retching and vomiting preceding the onset of pain has classically been associated with Boerhaave syndrome, approximately 25 to 45 percent of patients have no history of vomiting [9]. Patients may have crepitus on palpation of the chest wall due to subcutaneous emphysema. In patients with mediastinal emphysema, mediastinal crackling with each heartbeat may be heard on auscultation especially if the patient is in the left lateral decubitus position (Hamman's sign). However, these signs require at least an hour to develop after an esophageal perforation and even then are present in only a small proportion of patients [4]. Within hours of the perforation, patients can develop odynophagia, dyspnea, and sepsis and have fever, tachypnea, tachycardia, cyanosis, and hypotension on physical examination. A pleural effusion may also be detected"

How does this presentation not sound like Boerhaave's?

Edit: And to answer your question regarding where the subcutaneous emphysema comes from, the esophageal tear in Boerhaave's is a full thickness tear, as opposed to a Mallory-Weiss tear. Therefore, air is able to spread through the subcutaneous tissues following the tear with all the retching the patient is having.

Whether or not this is Boerhaave's syndrome is one thing, but as far as I'm concerned it is a fairly classic presentation as evidenced by the above.

 

[chocomorsel]

I had a similar case a couple of years ago. It was angioedema that did not seem that bad. I was green fresh from residency. The oral edema was just localized to the hard palate at this point and she was nasally in tone and telling me about her bout with this problem. It was the hereditary kind. Anyway, I did what the OP did with the glidescope, and propofol but instead of reaching straight for the ETT I got handed a bougie and didn't demand the ETT. I tried it, it was too floppy, and I aborted the procedure opting to wake her up, go to OR, and wait for the ENT.

I didn't see any more swelling as I was pulling out but when she woke up the edema had gotten significantly worse that she started freaking out and screaming and crashed. The ER doc grabbed a blade and did an emergent cricothyrodotomy as smooth and fast as I have ever seen. I have only ever seen three and two were with ENTs.

After discussing the case with ENT he said always, go down the nose with a FOB no matter how simple it might look. Because any stimulation with a bade can really escalate the edema quickly. Less stimulation the better.

When I asked the ER doc where he'd learned to do that, he said he used to practice in a city with lots of black folk and saw lots of ACE induced angioedema and had done four slash trachs in the past.

Learned my lesson that day. And I know I would have gotten in if I had only insisted on the ETT instead of trying the bougie, which I know I am not good at. I was hesitant and this lady almost died.

 

[camkiss]

How much Ketamine and how much versed? I'd guess a pretty good dose of K for him to tolerate a glide look without going nuts.

I like the moxie but not sure I'd take on the orals with that plan. But of course, we've all had patients that on paper tell you to go one way but once eyes on you decide you can be more aggressive, sounds like your assessment was correct.

Good job working with what you have, I'm sure that will be one of my first lessons once I get out, not all centers have anesthesia techs and FOBs ready to come running lol. If there's one thing I haven't gotten to do many of its an awake glide/DL.

For the residents here, this is NOT oral board management of this case, unless they offer to you that you don't have surgeons or a trach kit, etc. I used 5mg of Versed and 100mg of ketamine. My sphincter tone was exceptionally high. I knew this was either going to go well or he was getting a hole in his neck with the hopes of finding the right anatomy.

 

[Arch Guillotti]

If it's not that deep I would put and 18g angiocath in it for entraining o2. Or jet ventilation. This can buy some much needed time. And it tells the person where to cut if needed.

I don't disagree with this approach but how do you keep him from coughing?

 

[Mman]

For the residents here, this is NOT oral board management of this case, unless they offer to you that you don't have surgeons or a trach kit, etc. I used 5mg of Versed and 100mg of ketamine. My sphincter tone was exceptionally high. I knew this was either going to go well or he was getting a hole in his neck with the hopes of finding the right anatomy.

I dunno, I think that approach would pass muster on oral boards. It's certainly a reasonable and defensible way to do it. You just have to be prepared for them to take you down the pathway of it not working and you having to cut the neck and the patient dying.

High risk situation to be in and you gotta do something.

 

[Noyac]

I don't disagree with this approach but how do you keep him from coughing?

Well, you don't really. But at least you are in the trachea and can get some O2 in there. The entrained O2 doesn't make them cough. And the angiocath doesn't make them cough either as long as you don't shove it in aggressively. But if they do cough then hit them with some lido.

But I was waiting for someone to mention the obvious. What will append to the SQ emphysema if you start to use that angiocath? Think balloon. It's a last ditch effort I guess and probably not a very good one.

 

[deleted171991]

Lido or small doses of fentanyl.

In a tertiary center, the sphincter tone could have been decreased by an ECMO backup.

 

[dhb]

I'm afraind those proposing an awake fiberoptic would
a. Have a hard time getting good topicalization
b. Have a hard time visualizing with all thz soft tissue edema.
Awake glide vs awake trach for me.

 

[Robotic Wis-Hipple]

I'm afraind those proposing an awake fiberoptic would
a. Have a hard time getting good topicalization
b. Have a hard time visualizing with all thz soft tissue edema.
Awake glide vs awake trach for me.

Of course that's the worry, which is why you have to have your plan B, C, etc. But the counter argument is if you don't think you can get good enough topicalization to do an awake nasal how are you getting adequate topicalization to do an awake DL/glide?(obviously glide should be easier than DL) Putting a laryngoscope in an edematous oropharynx and continually expanding neck is just as likely if not more so to cause gagging/coughing. Unless you nail them with Ketamine/precedex etc which then I'd argue is no longer awake, just spontaneously breathing but at risk for complete airway collapse.

I still think on my orals I'll go awake FOI via nasal route and wait for the fact that the scope is broken and ENT/Gen Surg is not in house before lateralling to awake glide which will then cause airway collapse or increased swelling (misdiagnosed angioedema or Ludwigs etc) forcing me to slash vs 14g the neck.

 

[pgg]

Apparently, every time he coughs the SQ emphysema increases. So how do you keep this guy from coughing? You can't do a transtracheal injection because of the anatomy most likely and it makes them cough.

I don't disagree with this approach but how do you keep him from coughing?

I'm not sure that's really a big deal, and I don't think transtracheal lidocaine is contraindicated here.

He's already coughing. One more cough that coats his trachea and vocal cords with local, reduces subsequent coughing, facilitates securing the airway (via whatever means), and puts the means of jet ventilation in place seems like a terrific idea to me.

 

[dhb]

Of course that's the worry, which is why you have to have your plan B, C, etc. But the counter argument is if you don't think you can get good enough topicalization to do an awake nasal how are you getting adequate topicalization to do an awake DL/glide?.

Much faster to have a look with the glide than to find the cords with a fiber

 

[cchoukal]

Ventilation through the tube did not seem to worsen the sub q emphysema, so we were fairly certain at that point it was an esophageal injury (or that the injury was proximal to the ETT cuff, if tracheal).

It's great that it worked out, but if tracheal tear was in the differential (not that I agree it should've been, but...), you would have to worry about worsening the emphysema with positive pressure (presumably not with negative pressure, or, spontaneous ventilation). You note that it didn't occur, but what if it had? What would've been your plan? Hope that more gas went down the trachea than through it? Stop ventilating until the succ wore off and hope he resumes spontaneous ventilation before he codes? The alternative, as others have pointed out, would be topicalization (yes, he might cough, which is also a risk) followed by intubation without paralytic, so that he would continue spontaneous ventilation.

 

[Noyac]

It's great that it worked out, but if tracheal tear was in the differential (not that I agree it should've been, but...), you would have to worry about worsening the emphysema with positive pressure (presumably not with negative pressure, or, spontaneous ventilation). You note that it didn't occur, but what if it had? What would've been your plan? Hope that more gas went down the trachea than through it? Stop ventilating until the succ wore off and hope he resumes spontaneous ventilation before he codes? The alternative, as others have pointed out, would be topicalization (yes, he might cough, which is also a risk) followed by intubation without paralytic, so that he would continue spontaneous ventilation.

Good points, all of them.
So how would you have proceeded?

 

[camkiss]

It's great that it worked out, but if tracheal tear was in the differential (not that I agree it should've been, but...), you would have to worry about worsening the emphysema with positive pressure (presumably not with negative pressure, or, spontaneous ventilation). You note that it didn't occur, but what if it had? What would've been your plan? Hope that more gas went down the trachea than through it? Stop ventilating until the succ wore off and hope he resumes spontaneous ventilation before he codes? The alternative, as others have pointed out, would be topicalization (yes, he might cough, which is also a risk) followed by intubation without paralytic, so that he would continue spontaneous ventilation.

My plan at that point was to advance the tube to the right main stem and hopefully ventilate below the injury.

 

[caligas]

Much faster to have a look with the glide than to find the cords with a fiber

But keep in mind that a view with the glide does not guarantee intubation with the glide.

 

[cchoukal]

So how would you have proceeded?

I was hoping you wouldn't ask. I'm just here to point out others' foibles.

I would be more comfortable topicalizing (5% ointment, 4% spray, possibly transtracheal) and intubating via Glidescope. Although the risk of cough is present, and coughing could worsen the sub-q air, I would expect a) it to be temporary, and b) he would still continue to ventilate, whereas with paralysis, it is possible I would not be able to ventilate and the sub-q air could get massively worse. Unlikely, sure, but IF it happened, it would be terrible.

 

[Urzuz]

But I like being a smart-ass. And I have been hitting the books pretty hard recently.....

I know what Boerhaave's is. This patient's presentation just did not sound like Boerhaave's so I still think tracheal tear is the more likely diagnosis.

Still anxiously waiting for you to explain why this patient's presentation sounds more like a tracheal tear than Boerhaave syndrome to you.

 

[Chloroform4Life]

Still anxiously waiting for you to explain why this patient's presentation sounds more like a tracheal tear than Boerhaave syndrome to you.

B/c coughing made the subcutaneous emphesema worse.