Mediastinal Air
	Date: Thu, 21 Aug 1997 18:34:46 -0400 (EDT) From: Shelly [Swilt595@aol.com] How do you work up a patient that has sustained blunt trauma who has mediastinal air and no other findings? Does every patient with mediastinal air need a full workup or can you monitor them? I ask these questions because the surgeons that I work with have mixed responses so I wanted to get some more opinions. We have recently had 2 patients with mediastinal air after blunt trauma with no other findings initially. Are there times that you can just observe this type of patient? If so, are there clinical findings that would lead you to do more of a workup if they were present? I appreciate any advice. Shelly Trauma Coordinator
	Date: Fri, 22 Aug 1997 19:57:56 +0100 From: Dr. Ed Walker [Ed_trauma@limeland.demon.co.uk] We had one recently - about 10 days following discharge after a fairly minor RTA (road traffic accident), a 20 year old female presented with L shoulder pain. CXR showed a rim of air around the L side of the mediastinum. We got all excited about this is the Emergency dept., but the surgeons decided for conservative / expectant treatment, which means 'wait and see.' Nothing happened. She got better, and CXR a week later was normal.
	Date: Fri, 22 Aug 1997 14:03:42 -0600 From: NigthSurgeon Shelly Mediastinal air is a fairly common finding after chest trauma , It all depends on the patient, basically exclude by all means a Oesophageal and bronquial tear injury , and if negative I think its safe to observe and to have a X ray follow up for a couple of days. If it increases then do the complete workout. Dr. Porfirio H. Lango Trauma Surgeon Hospital General de Mazatlan Mexico
	Date: Sat, 23 Aug 1997 20:03:15 +0000 From: Andrew & Diane Dean [andidean@cbl.com.au] I've had the same problem. A patient with a stab wound to the chest, clinically exploring it revealed open wound to depth of s/cut fat over R 4th ICS; no pneumothorax on erect CXR, but small amount s/cut emphysema in axilla. The surgeons were keen to fix this in the OR [I had thought of fixing it in the ED after exploration reassured me of the limited margins]; due to the XRay s/cut emphysema, and intended GA, a chest tube was planned on that side. ?Excessive caution ?air migrating northward from the 5cm wound during tissue movement. Am I alone in feeling that this was 'overkill'? Regards, AD. Best Wishes, Andrew Dean
	Date: Sat, 23 Aug 1997 15:20:43 +0200 From: Jan De Waele [jan.dewaele@rug.ac.be] Try the 'Surgical Clinincs of Northern America' from August 1996. The chapter 'Complex Thoracic Injuries' clearly describes the managment of the patient with extra anatomic air. Jan De Waele, M.D. Res. Dep. of Surgery Univerisity Hosptal Ghent Belgium
	Date: Fri, 22 Aug 1997 06:28:30 -0400 From: Eric Frykberg M.D. Shelly-- It is very typical for those who do not take primary responsibility of the care of a patient to think there there is alwyas ONE RIGHT way to do things--wouldn't it be great if life were really that simple? Medicine is largely not amenable to algorithmic management--algorithms have a place, but they are frequently misinterpreted by the uninformed--they may be useful guides, not dogmatic mandates! Mediastinal air is from the loss of integrity of some nearby air-containing structure, i.e. the lung, the esophagus, and possibly even intraperitoneal viscera--the lung is the most likely source following blunt trauma, in which case the broken alveoli have released air which has dissected into the mediastinum--if it goes the other way and out into the pleura, you have a pneumothorax. Management depends first, as in all medicine, on its effects on the patient, and what you are most worried about is that the air does not compromise cardiac function--enough of a pressure buildup can actually cause tamponade, tho unusual. Next, consider those sources that could be of potential harm to the patient--if from the lung, and it doesn't worsen, no treatment is necessary. If from the esophagus, it is worth finding early rather than waiting for florid mediastinitis to develop, and for that reason I would generally image the esophagus with a contrast swallow--if you feel esophagoscopy is the better method(I don't), do that. The possibility of a ruptured intra-abdominal viscus can easily be excluded by the clinical exam and maybe an uprite CXR. The main thing is to continue to watch the patient for further developments. I couldn't argue with those who would simply watch the patient and do nothing for now--that could easily be defended as well--don't think that something must be wrong if you hear different approaches from different physicians--they may all be appropriate--it just means you are in real life, and not fantasyland! Eric Frykberg, M.D. Jacksonville, Fl