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发表于 23-10-2017 11:38 PM
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本帖最后由 jinreung 于 23-10-2017 11:44 PM 编辑
Visual Diagnosis in Emergency Medicine
‘‘SCREAMING YOUR LUNGS OUT!’’ A CASE OF BOY BAND-INDUCED PNEUMOTHORAX, PNEUMOMEDIASTINUM, AND PNEUMORETROPHARYNGEUM
J Mack Slaughter Jr., MD and Lynn Roppolo, MD
Department of Emergency Medicine, UT Southwestern Medical Center, University of Texas Southwestern/Parkland Health & Hospital System, Dallas, Texas
Reprint Address: J. Mack Slaughter, Jr.,MD, Department of Emergency Medicine, UT Southwestern Medical Center, University of Texas Southwestern/Parkland Health & Hospital System, 5323 Harry Hines Blvd., Dallas, TX 75390-8575.
INTRODUCTION
Spontaneous pneumothorax, pneumomediastinum, and pneumoretropharyngeum (also described in the literature as retropharyngeal emphysema) are each defined as atraumatic development of air within their respective anatomical spaces. Typical triggers for these conditions include acute asthma exacerbations, respiratory infections, vomiting, and barotrauma (1–5). Many cases involve underlying lung disorders (6). We report a case of these three conditions in a young female with no known underlying lung problems that presented after forceful screaming.
CASE REPORT
A 16-year-old female with a history of type 1 diabetes presented to the Emergency Department (ED) with short- ness of breath. She denied chest pain or sore throat. She reported a sudden onset of symptoms after forceful screaming at the ‘‘One Direction’’ concert the night prior. She denied any preceding emesis, odynophagia, or cough. Her physical examination revealed tachypnea to 22 breaths/min with normal breath sounds and no respira- tory distress. A Hamman’s crunch was not appreciated. Oxygen saturations were 100% on room air. Significant diffuse crepitus was palpated over the anterior neck and chest wall. Her laboratory results showed an elevated random glucose to 261 with no acidosis or anion gap. Chest and neck soft tissue x-ray studies were obtained, demonstrating extensive subcutaneous emphysema in anterior neck and retropharyngeal space (Figure 1) with associated pneumomediastinum and small bilateral pneumothoraces (Figure 2). Computed tomography of the chest and neck did not reveal an underlying structural disorder leading to these radiographic findings. The patient was placed on 100% O2 via nonrebreather and was admitted to the hospital for observation. After an uneventful period of observation with an unchanged repeat chest x-ray study, the patient was discharged the following day with no further visits for this problem.
DISCUSSION
Spontaneous pneumothorax, pneumomediastinum, and pneumoretropharyngeum are uncommon diagnoses individually, and furthermore, the combination of all three diagnoses has yet to be described in medical literature. The mechanism for this constellation of disorders is also extraordinary. Shouting has been described as the cause of pneumomediastinum in only a handful of case reports (7,8). The patients in these reports had a benign course, with the exception of one case that led to mediastinitis, parapneumonic effusions, and a protracted hospital stay with broad-spectrum antibiotic infusion (7). This particular patient was noted to have symptoms consistent with pharyngitis prior to the onset of spontaneous pneumomediastinum. There is only one case linking shouting to pneumoretropharyngeum, or retropharyngeal emphysema. In this case, the onset was secondary to forceful singing (9). Spontaneous pneumothorax has been linked with multiple activities leading to acute increases in transpulmonary pressure (e.g., weight lifting, diving, and military flying) (10). This particular case suggests that forceful screaming during pop concerts should be added to that list.
Stable patients with a small primary spontaneous pneumothorax (< 2 to 3 cm between lung and chest wall on chest x-ray study) can be given supplemental oxygen and observed for 6 h. If a repeat chest x-ray study shows no progression of the pneumothorax, the patient may then be safely discharged home from the ED with return precautions if there is access to immediate emergency care (11). For pneumomediastinum/pneumoretropharyngeum, computed tomography of the neck and chest is recommended to rule out identifiable causes. Barium swallow and ear, nose, and throat endoscopy are also indicated if pharyngoesophageal perforation is suspected (5). Although progression of pneumoretropharyngeum is rare, there is a case report of a 2-year-old child who developed this condition as a consequence of severe coughing spells. During this toddler’s hospital stay, he failed conservative therapy and developed significant airway obstruction, requiring intubation and chest tube placement (12). If no cause for the patient’s spontaneous pneumomediastinum or pneumoretropharyngeum is identified, we recommend admission of the patient for observation, placing the patient on nothing by mouth, administration of 100% oxygen, and avoidance of maneu- vers that increase pulmonary pressure (see above for examples) (13–15).
以上是整個case report的原文。
余是冒著版權的危險，單純地學術性分享。
三個地方同時爆，@wjleong15，你有什麼看法？
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我米有扭曲。但是你的 point 就是這樣的嘛。
原來。。抱歉咯。
发表于 23-10-2017 01:48 PM
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