Boerhaave's Syndrome
You are the cardiothoracic surgery CT1 asked to see a 48-year old, overweight, man who developed severe retrosternal chest pain after eating a large meal then vomiting copiously. The referring doctor tells you that he currently has a temperature of 38.5. How would you proceed?
Example answer introduction
I suspect that this gentleman may have Boerhaave syndrome, a ruptured oesophagus as a result of forceful vomiting. I would assess this patient using an A-E approach, take a focused history and perform a thoracoabdominal examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions.
Initial Assessment and Simultaneous Resuscitation
On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.
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Airway
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Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen
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Circulation
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Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic
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IV access - large bore and bloods including CRP
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Give fluid challenge of 250ml crystalloid solution if evidence of shock
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If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol
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Disability - GCS, pupillary response, blood sugar, temperature
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Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!
During this acute phase state remember to provide constant reassessment
During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, Trop I, clotting studies, Group and Save and blood and urine cultures if spiking a temperature.
Focused history
I would ask about:
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Allergies
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Medications
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Past medical history - oesophagitis, Barret’s oesophagus, recent upper GI endoscopy, infections ulcers.
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Last meal
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Events leading up to this point - nature of pain, nausea and vomiting,
Examination
Thoraco-abdominal examination
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Inspect – chest wall movements, abdominal distention, surgical/traumatic scars
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Auscultate – Hamman’s sign, diminished or absent bowel sounds
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Palpate – surgical emphysema, tenderness, guarding, peritonism, rebound tenderness
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Percussion – Dull, Resonant or hyper-resonant
Example questions to progress the station
Q1 - You find him to be floridly septic and continues to complain of chest pain. What investigations would you order.
I would consider:
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Urine dip
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Abdominal x-ray – Evidence of bowel obstruction
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Erect chest x-ray – Air under diaphragm signifying perforated viscus.
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Ultrasound abdomen – gallstones, bile duct dilatation
Q2 - The chest X-ray shows a widened mediastinum and pneumomediastinum with a normal abdominal examination. What does this indicate and how would you proceed?
I would instigate treatment for a suspected perforated oesophagus.
Initial management
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IV antibiotics according to local protocol
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Analgesia according to the WHO pain ladder
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Proton-pump inhibitor
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IV crystalloids to maintain urine output of 0.5ml/kg/hr
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Keep nil-by-mouth
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Inform the Cardiothoracic Registrar to review the patient – this patient will need water-soluble contrast swallow if stable and CT thorax and abdomen.
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VTE Prophylaxis
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Keep patient and any relatives informed
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Document, document, document!!!
