Saturday, June 19, 2010

Answer this case of Acute Chest Pain

A 42-year-old man found vomiting in the street is brought to the ED by emergency medical services (EMS). He has a known history of alcohol abuse with multiple presentations for intoxication.
Today, the patient complains of acute onset and persistent chest pain associated with dysphagia and pain upon flexing his neck. His blood pressure is 115/70 mm Hg, heart rate of 101 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation of 97% on room air. As you listen to his heart, you hear a crunching sound. His abdomen is soft with mild epigastric tenderness. The ECG is sinus tachycardia without ST-T wave abnormalities. On chest x-ray, there is air in the mediastinum.

What is the most likely diagnosis?

a.Acute coronary syndrome (ACS)
c.Alcoholic ketoacidosis
d.Esophageal perforation
e.Aortic dissection

The right answer is D
Esophageal perforation is
potentially life-threatening conditions that can result from any valsalva-like maneuver, including childbirth, cough, and heavy lifting. Alcoholics are at risk due to their frequent vomiting. The most common cause of esophageal perforation is from iatrogenic causes such as a complication from upper endoscopy. The classic physical exam finding is mediastinal or cervical emphysema. This is noted on palpation of the chest wall or by a crunching sound heard on auscultation, also known as Hamman’s sign.
(a) The patient has no ST-T wave abnormalities on ECG. The history and physical exam are not consistent with ACS. (b)Alcoholics have a high incidence of pancreatitis and can present with epigastric tenderness, however they usually don’t have mediastinal air on radiography. (c) Alcohol ketoacidosis usually occurs in a heavy alcohol user who has temporarily stopped drinking and eating. Aortic dissection (e) usually occurs in patients with chronic hypertension or connective tissue disorders. They
should not have Hamman’s sign.

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