A
27 year old patient involved in a motor vehicle accident is bought to the
emergency room alert, cooperative, and hemodynamically stable.
The patient's respiratory rate is 24/minute and the arterial blood gas
shows pH 7.49, pO2 95 mmHg, pCO2 30 mmHg. The
chest radiograph obtained in the emergency room shows pneumomediastinum with no
pneumothorax. The initial
management of this injury should include
A.
bronchoscopy.
B.
intubation.
C.
observation.
D.
thoracoscopy.
E.
tube thoracostomy.
Pneumomediastinum
is the presence of air or gas in the mediastinum. The most common sites of airway injury from blunt trauma are
the mainstem bronchi within 2.5 cm of the carina and the middle lobe bronchus.
These injuries are best evaluated using fiberoptic bronchoscopy.
Esophageal perforations are an unlikely cause of peumomediastinum after
blunt trauma. In patients with
pre-existing esophageal disease or other risk factors for esophageal
perforation, an esophagogram with water-soluble medium can be obtained when
vital signs have been stabilized.
Although
the evaluation of pneumomediastinum may not take priority over serious
co-existing injuries, observation alone is not appropriate after significant
blunt chest trauma. Thoracoscopy
plays no role in the evaluation of pneumomediastinum after chest trauma.
With no apparent pneumothorax or hemothorax on chest radiograph, there is
no indication for tube thoracostomy. The
need for a chest tube, however, should be continuously reassessed and considered
with any evidence of hemodynamic decompensation or if positive pressure
ventilation is required.