富阳卫生信息Title.ppt

Snap, crackle, pop! Lester Mercuur 09 Nov 2006 Objectives Case presentation Presentation of X-rays Discussion of the differential diagnosis Back to the case Case 71yo lady referred from Claresholm where she had been admitted the previous day with: Feeling unwell for 3 days with chest discomfort; Vomiting coffee-ground material x 1 day PMH: Depression; CHF; hiatus hernia; no previous surgeries Meds: Maxeran; Prevacid; Trazadone; Lasix Hospitalised overnight with IV hydration and analgesics. Case Sudden onset of dyspnoea at 0500 on day of referral to FMC with chest discomfort. T 37.7oC; P 97 RR 40; BP 129/78 Physician noticed facial swelling and a pulmonary infiltrate on CXR and referred patient as a SVC syndrome. No improvement with Ventolin and Lasix. WBC 10.8; Hb 129; MCV 89; Plt 285 T/F to FMC Case On arrival at 0830, 71 yo female with resp distress. T 36.6oC P100 BP127/60 RR36 O2 sat on RA 91% Periorbital swelling bilaterally. Differential diagnosis Pneumomediastinum 2o to oesophageal perforation: FB Boerhaave Syndrome Complication of hiatus hernia Course in the ED Repeat CXR Course in the ED Repeat CXR CT chest – water-soluble contrast (Gastrografin) Blood cultures Antibiotics Thoracic Surgery consult OR Differential diagnosis Oesophageal perforation with pneumomediastinum: Boerhaave Syndrome Complication of hiatus hernia Oesophageal perforations Oesophagus most vulnerable to perforation 50% due to iatrogenic causes Rates increased with procedures – balloon dilatation of strictures; variceal ligation; sclerotherapy 15% due to FB, caustic ingestions 15% due to Boerhaave Syndrome 10% - trauma Risk factors – Hiatus hernia; carcinoma; strictures; radiation; Barrett’s; oesophageal varices; achalasia Oesophageal perforation Presentation may vary according to: Location of tear Upper - neck/upper chest Mid or lower - interscapular or epigastric pain Cause of the tear (Iatrogenic/ Boerhaave) Time from perforation to presentation Early po