Question 19

College answer

Not available.

Discussion

This question is virtually identical to Question 16 from the second paper of 2016.

Immediate management

• Attention to ABCs and correction of immediately identified life-threatening features
• Detailed history and thorough physical examination
• Assessment of airway patency and intubation as needed
• Maintenance of normoxia with supplemental oxygen
• Maintenance of normotension with fluid resuscitation and vasopressors as needed
• Analgesia and sedation
• Attention to broad-spectrum antibiotic cover, including antifungal agents

Investigations:

• CXR looking for pneumomediastinum
• CT chest with contrast
• Gastrograffin swallow (not barium)
• Intercostal catheter to drain pleural effusion and analyse it, looking for acidity (suggestive of gastric contents) and food particles.

Specific Management

• Thoracoscopic or open surgical management;
• alternatively, endoscopic stent placement
• alternatively, conservative antibiotic-based management and supportive care in ICU
• alternatively, palliative care

Supportive management:

• TPN: they won't be eating for a while
• Broad-spectrum antibiotics (Tazocin is a fine choice)
• Proton pump inhibitors to encourage the process of oesophageal repair
• Eventually, these people end up having surgery - but it is delayed until the empyema or mediastinal abscess are well-circumscribed.

Idiosyncratic ICU issues

• No positive pressure without intubation: even high flow nasal prongs can blow gas into the mediastinum. Thus, no bag-mask ventilation with intubation. All of these patients should be getting an RSI-like induction.

Social issues

• This is an iatrogenic complication. Full open disclosure must be carried out
• A family discussion of the possible outcome must take place, ideally led by the team of perforators.
• The mortality- irrespective of the management approach - will be in the order of 40% (Biancari et al, 2014)