Cardiac arrest due to a missed diagnosis of Boerhaave's syndrome

Davies, Jennifer; Spitzer, David; Phylactou, Maria; Glasser, Martin

doi:10.1136/bcr-2014-208659

Cited by 5 publications

(5 citation statements)

References 11 publications

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“…There have been several cases of esophageal perforation presenting as an acute myocardial infarction or cardiac arrest, but cardiac arrhythmia has only been noted in 2 cases upon literature review. 9 , 16 This patient with third degree heart block, presenting with symptomatic bradyarrhythmia, would be a candidate for implanted permanent pacemaker (class I indication). However, the decision of when to place the pacemaker was complicated by his comorbidities and the presentation with sepsis.…”

Section: Discussionmentioning

confidence: 99%

Boerhaave’s Syndrome Presenting in the Setting of Third-Degree Heart Block

Redan,

Croteau,

Gaughan

2024

CRSLS

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Introduction: Boerhaave’s syndrome, or the spontaneous transmural perforation of the esophagus, is typically thought to be due to an increase in esophageal pressure such as that which occurs during vomiting or retching. Another common etiology of esophageal perforation is esophageal instrumentation, such as during esophagogastroduodenoscopy or transesophageal echocardiography. This life-threatening condition requires prompt diagnosis and treatment to prevent patient demise. While a history of vomiting can aid in diagnosis, this history can be difficult to elicit in an unconscious patient or may be altogether absent. Additionally, Boerhaave’s syndrome can present similarly to more common upper gastrointestinal or cardiac conditions. Since mortality increases with delays in diagnosis and treatment, it is imperative that clinicians maintain a high level of suspicion for Boerhaave’s syndrome and initiate treatment urgently. Case Description: This report presents a 76-year-old man who presented to the emergency department after a history of several syncopal episodes and was found to be in complete heart block. Two days later, he acutely developed abdominal distention and coffee ground emesis. As the medical team was able to gather more history from the patient and his family, it was revealed that he had associated vomiting with his episodes of syncope. CT scan of the abdomen and pelvis demonstrated pneumomediastinum concerning for esophageal perforation. His clinical status subsequently deteriorated. He was intubated and a temporary transvenous pacer was placed before being transferred to our facility for emergent surgery. Discussion: Complete heart block in the setting of Boerhaave’s syndrome is exceptionally rare, with only 2 cases reported in the literature. The decision to place a pacemaker in the setting of esophageal perforation/sepsis is complicated and depends on the patient’s bacteremia status related to noncardiac comorbidities. Clearly this case represents the need for excellent multidisciplinary decision-making processes with excellent communication between hospital staff and all caretakers. Expeditious diagnosis and treatment of esophageal perforation is essential to prevent leaking of gastric contents into the mediastinum and worsening of cardiac complications and sepsis. Additionally, critical timing of various surgical procedures, especially the need for a permanent pacemaker implant with bacteremia is a complicated process not well described in the surgical literature.

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Section: Discussionmentioning

confidence: 99%

Boerhaave’s Syndrome Presenting in the Setting of Third-Degree Heart Block

Redan,

Croteau,

Gaughan

2024

CRSLS

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“…There are reports in the literature of respiratory arrest and subsequent death in patients with subcutaneous emphysema. 9 – 11 Several theories exist behind the deterioration, including restricted thoracic expansion from air in the respiratory muscles and cranial migration of air into the cervical visceral space, which hosts the trachea and recurrent laryngeal nerve. Cranial migration of air would manifest as a high-pitched voice or of a nasal quality, secondary to laryngeal disruption.…”

Section: Discussionmentioning

confidence: 99%

Extensive subcutaneous emphysema following lobectomy

Fadhlillah

Wei

2018

SAGE Open Medical Case Reports

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We present a case report of extensive subcutaneous emphysema secondary to an elective left upper lobectomy. A 65-year-old gentleman was brought into a London teaching hospital’s Accident and Emergency department following report of severe swelling. He was mistakenly treated by the paramedics as an allergic reaction and given hydrocortisone and salbutamol nebulisers with no effect. Upon arrival, the patient had widespread crepitus extending from his peri-orbital muscles down to mid-torso. A computer tomography scan revealed a pleuro-cutaneous fistula at the site of a recently sited chest drain, with extensive emphysema and a pneumothorax. A Seldinger chest drain was successfully inserted under blind technique following two attempts. This case highlights the risk of subcutaneous emphysema following thoracic surgery, the importance of correct diagnosis and the difficulties of left-sided intercostal drains in patients with subcutaneous emphysema.

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“…In patients with Boerhaave’s syndrome with pleural rupture, the resulting mediastinitis can rapidly lead to severe pneumonia and death [1], [2]. Surgery is the conventional treatment for patients with esophageal rupture.…”

Section: Introductionmentioning

confidence: 99%

“…Spontaneous rupture of the esophagus involves all layers of the esophageal wall due to a sudden increase in intraluminal pressure, first documented by Herman Boerhaave in 1724. In patients with Boerhaave’s syndrome with pleural rupture, the resulting mediastinitis can rapidly lead to severe pneumonia and death [1] , [2] . Surgery is the conventional treatment for patients with esophageal rupture.…”

Section: Introductionmentioning

confidence: 99%