BOF: 2.65
A 26year old female presents with sudden onset of
retrosternal chest pain. On direct questioning she reveals that the pain came
on shortly after smoking marijuana.
On examination she has a pulse rate of 110 beats per
minute, BP 110/60, JVP not elevated, trachea midline, apex not displaced.
On auscultation a crunching sound is heard in systole.
Respiratory and abdominal examination is unremarkable.
No abnormality is seen on the plain x-ray of her chest,
ECG shows T inversion in the anterior chest leads.
Which of the following investigations is likely to
confirm your diagnosis?
a)
Coronary angiogram
b)
Upper gastrointestinal endoscopy
c)
VQ scan
d)
Chest CT scan
e)
Gastograffin swallow
Answer:
d)
The sudden onset of chest pain with the finding of a
pericardial crunch (Hamman’s sign) suggests the patient has developed a
spontaneous pneumomediastinum.
The normal respiratory examination and normal plain x-ray
of the chest will exclude pneumothorax.
Lateral chest x-ray is likely to show air in the
mediastinum but CT of the chest will be more accurate.
Spontaneous pneumomediastinum is caused by alveolar
rupture with the released air subsequently dissecting the tissues and
travelling proximally to reach the mediastinum
It may be caused by any manoeuvre that increases alveolar
pressure such as:
Forceful coughing, crying, or
shouting
Vomiting, defecation, and
Valsalva manoeuvre
Strenuous athletic activity,
diving, flying, playing woodwind instruments, and childbirth
Spirometry.
COPD
Respiratory tract infections
Foreign body aspiration
Mechanical ventilation
Inhalation of drugs may such as marijuana and cocaine may
also cause spontaneous pneumomediastinum
Management is conservative
Rarely mediastinoscopy to relieve life threatening
complications and placement of mediastinal drainage tubes
