Pneumomediastinal Tamponade

Today's POTD came as a request from the Maimonides Attending Group Chat! This was a request after the Pitt, so taking a play out of Dr. Dan Ye's book to talk about case that is described in the latest episode. 


So without further adue lets look at some pneumomediastium specifically pneumomediastium causing tamponade.


Pneumomediastium: air present in the mediastinum, usually this occurs from air extravastaing from within the airways/lungs or esophagus and migrates into the mediastium. This air then dissects the cervical subcutanous tissues, epidural space, pericardium, and/or peritoneal cavity. 


Pneumomediastium is either typically spontaneous, rare, and typically self limited. Consider risk factors including smoking/tobacco use, recreational drug inhalation. Other causes include intrinsic lung and airway causes including asthma, COPD, bronchiectasis, COPD, ILDz, lung cancer, foreign body, increased intrathoracic pressure (forceful sneezing), increased intravagal tone (such as with childbirth, excessive vomiting, or strenous physical activities). Other iatrogenic cauases include: endoscopy, intubation, central line placement, thoracostomy, or chest/abdominal surgeries, and probably most commonly: traumatic causes: blunt trauma, penetrating trauma, or blast injuries. 



In the Pitt, **SPOILER ALERT**, the patient was shot in the chest and had a penetrating trauma.


Spontaneous pneumomediastum can also present with younger males of tall structure with low body mass. This spontaneous pneumomediastium occurs because of Macklin phenomenon: increased intra-aveolar pressure --> alveolar rupture --> air dissects into peribronchial and perivascular sheaths --> air progresses itno mediastium and surrounding tissues. 


Presentation: 

Most of the time this occurs with retrosternal chest apin that may radiate into the back or neck. 

On physical exam, these patients present with subcutaneous emphysema 

Other signs and symptoms include: rhinolalia (nasal tone of speech), dysphonia, neck swelling, hoarsness, tachycardia or tachypnea 


Diagnosis: 

Diagnosis is made usually on xray, and clinical diagnosis. 

On CXR you may see subcutaneous emphysema, elevated thymus (in peds patients), air around the pulmonary arteries, V shape between the descending aorta and left hemidiaphragm, double bronchial wall, or pleural effusion.


In pneumomediastium causing tamponade, these patients may have explained hypotension. Normally when we think about tamponade, we are able to be clused in with ultrasound findings, pneumomediastium on ultrasound may be seen as the "air gap" sign which would appear as sonographic echos, usually seen with M mode, that obsecure the cardiac structures underneath. If you have ever tried to place an ultrasound probe on a patient's chest with subq emphysema, you see nearly nothing, so this is definitiely more a clinical diagnosis to consider with unexplained hypotension in someone with subq emphysema. 


Tension pneumomediastinum/tamponade leads to compression of great vessels and compromises venous return --> hypotension and hypoxemia 


Management of tension pneumomediastinum that causes tamponade physiology: 

In the show, the patient got bilateral "blowholes": performed by a 2 cm incision infraclavicular through the skin and prepectoral fascia 

Other methods described include b/l chest tubes, placement of penrose drains into the neck 


Otherwise pneumomediastium is treated with supportive care and usually resolves on its own. 


Until next time friends!

Fleming AM, Zambetti BR, Valaulikar GS. Bedside Mediastinotomy for Tension Pneumomediastinum With Tamponade in COVID-19. Ann Thorac Surg. 2021 Oct;112(4):e265-e266. doi: 10.1016/j.athoracsur.2021.01.032. Epub 2021 Jan 30. PMID: 33529601; PMCID: PMC8402946


Iteen AJ, Bianchi W, Sharman T. Pneumomediastinum. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557440/

Sciortino CM, Mundinger GS, Kuwayama DP, Yang SC, Sussman MS. Case report: treatment of severe subcutaneous emphysema with a negative pressure wound therapy dressing. Eplasty. 2009;9:e1. Epub 2009 Jan 7. PMID: 19198645; PMCID: PMC2627309.

https://radiopaedia.org/articles/pneumomediastinum?lang=us

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Anticoagulation Reversal

Today I want to talk about anticoagulation reversal. I happened to be on Northside when a patient on dabigatran had an unwitnessed fall with some minor head trauma and got me thinking about my reversal agents, and here's the POTD. 


First it’s worth mentioning when to reverse anticoagulation. The first step to looking at anticoagulation is to determine why the patient is on it and recognizing that reversing the patient is putting them at some sort of risk. Usually within our patient population, patients are on AC for afib,  hx of strokes, though other considerations include any sort of hypercoagulable state. Reversing AC should be considered in life threatening bleeding in the ED. 


Anticoagulation: Warfarin (brand name Coumadin)

  • Can be evaluated by INR 

  • Intracranial hemorrhage: immediately give PCC 

  • Reversal: 

    • 10 mg IV Vitamin K over 30 minute + PCC or FFP 

      • Of note- PCC/FFP will only work for approximately 8 hours so please give with vitamin K 

    • For supratherapeutic INR with no life threatening bleeding, slowly treat: 

      • INR 3-5: 

        • hold warfarin 

      • INR 5-9: 

        • hold warfarin 

        • Vitamin K (1-2.5 mg PO or IV) if risk for bleeding 

      • INR >9: 

        • Hold warfarin 

        • Vitamin K 2.5-5 mg PO/IV 

Anticoagulant: Dabigatran 

  • Can be evaluated by PTT and thrombin time 

  • Reversal: 

    • Idarucizumab 5 g 

    • Dabigatran can be dialyzed out 


Anticoagulation: Factor Xa inhibitors (-xaban most commonly apixaban)

  • Can be evaluated through INR (normal INR goes against a significant drug level though does not exclude it entirely)

  • Reversal: 

    • 4 Factor PCC (KCentra) 

    • Adnexanet Alfa may be considered if available though v expensive 


Thrombolytic: tPA 

  • Order INR/PTT/fibrinogen though do not wait for results to reverse 

  • Reversal: 

    • Tranexamic acid: 

      • 1 g IV loading dose followed by 1 g infused over the next hour

      • Cryoprecipitate: start with 10 units 

    • Options: FFPs 2 units and platelet transfusions 


Anticoagulation: 

  • Heparin/LMWH: 

    • Measure with PTT

    • Reverse with protamine 

      • Dosing for protamine is quite intricate and depends on bolus, infusions and timing of both. I would recommend coordinating with pharmacy directly. 


Antiplatelet: 

  • Could consider TEG or platelet function assays 

  • Reversal: 

    • Desmopressin (DDAVP) 0.3-0.4 ug/kg infuse over 20-30 minutes 



Hopefully this helps as a quick reference, especially for those of us who will be sadly leaving Maimo and our beautiful anticoagulation orderset that makes reversing all of these things downstairs as painless as possible. 

https://emcrit.org/ibcc/reverse/


Aldhaeefi M, Badreldin HA, Alsuwayyid F, Alqahtani T, Alshaya O, Al Yami MS, Bin Saleh K, Al Harbi SA, Alshaya AI. Practical Guide for Anticoagulant and Antiplatelet Reversal in Clinical Practice. Pharmacy (Basel). 2023 Feb 11;11(1):34. doi: 10.3390/pharmacy11010034. PMID: 36827672; PMCID: PMC9963371.

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Terminating Adult and Pediatric Traumatic Arrests

This POTD is a sensitive one, it's one that I was actually asked to look into a week ago, but after the events of this weekend/this morning I felt it was even more appropriate to take a look at. I know that this may be too soon for some, I encourage you all to reach out to someone you trust, take some time for yourself, and take care of yourself. There is no one right way to process the tragedy we see on a regular basis especially after this weekend. If you need a listening ear, I am always here. 


Today’s POTD is talking about when to terminate the pediatric traumatic arrest. When we think about traumatic arrests we think about penetrating traumatic arrests vs blunt traumatic arrests. 


Blunt Traumatic: 

  • Injuries that occur from forceful impact without penetrating the skin

  • Examples: MVCs, falls, assault


Penetrating Trauma: 

  • Stab wounds, gunshots, impaled objects 


Pediatric traumatic cardiac arrests: 

  • Traumatic pediatric cardiac arrests accounts for 22% of all out of hospital cardiac arrests in pediatric patients 

  • It has become more of an acceptable practice to terminate adult traumatic arrests in the field, though one study showed that this occurred less than <1% of the time


Intervening In traumatic arrests, in adult traumatic arrests, we must consider when to further intervene. When thinking about these different traumas we think about how to intervene, including with hemorrhage control, usually this starts with chest tubes, and can progress to a thoracotomy.  Other hospitals also have REBOAs (resuscitative endovascular balloon occlusion of the aorta) which may also be used. At Maimo, we do not have REBOAs. With this in mind, a brief review of when to intervene for adult traumatic arrests: 

  • Penetrating Trauma

    • Cardiac arrest with: 

      • Signs of life (spontaneous respiratory effort, spontaneous motor function/movement, electric cardiac activity, blood pressure (palpable or measureable), carotid pulse palpable, pupillary response to light)

    • Cardiac arrest without signs of life and <15 minutes of CPR 

    • >1500 ml of blood from the chest tube with persistent hypotension 

    • Refractory shock despite adequate volume resuscitation 

  • Blunt Trauma: 

    • Cardiac arrest with at least one sign of life observed in the hospital or lost just prior to arrival at the hospital 

    • <10 minutes of pre-hospital CPR 

    • Refractory shock despite adequate volume resuscitation 

    • >1500 ml from chest tube 


Intervening for pediatric arrests: 

  • Looking at NYC EMS Protocols specifically for pediatric patients: CPR is required for pediatric patients with: 

  • Severe bradycardia (HR <60 bpm) AND signs of shock or AMS

  • CPR should be continued until any of the following: 

    • ROSC: return of spontaneous circulation

    • Resuscitative efforts have been transferred to equal or higher level of training

    • Qualified physician assumes responsibility

    • Present of valid DNR/MOLST


So all of this brings us to the original question- when should we terminate pediatric arrests in the field? 

  • A recent study looked at both neurological outcomes and ROSC in cases of out of hospital pediatric cardiac arrests. Poor neurological outcomes and termination of care were recommended when: 

    • Unwitnessed arrest 

    • Asystole 

    • Arrest not due to drowning or electrocution 

    • No sustained ROSC

    • No bystander CPR 

  • So is this really applicable to our population? 

    • Maybe? Terminating in the field should be considered with any obvious signs of death, extreme lividity, rigor mortis, tissue decompensation, obvious mortal injury, submersion >1 hour

  • For traumatic pediatric arrests: 

    • Most studies do not support a thoracotomy though will be at the discretion of the trauma attending 


With all things considered, it is possible and should be considered terminating pediatric arrests in the field. This should be done in conjunction with online medical control, the attending, and consideration of EMS who may stuck performing CPR/ALCS in front of crowds of strangers and loved ones who may not understand the nuance of stopping compressions in the field and why it may be necessary for their sakes to transport these patients.

Niemann M, Graef F, Hahn F, Schilling EC, Maleitzke T, Tsitsilonis S, Stöckle U, Märdian S. Emergency thoracotomies in traumatic cardiac arrests following blunt trauma - experiences from a German level I trauma center. Eur J Trauma Emerg Surg. 2023 Oct;49(5):2177-2185. doi: 10.1007/s00068-023-02289-7. Epub 2023 Jun 3. PMID: 37270467; PMCID: PMC10519862.


https://www.upstate.edu/surgery/pdf/healthcare/trauma/traumatic-arrest.pdf


https://www.jems.com/patient-care/cardiac-resuscitation/traumatic-cardiac-arrest-tca-maybe-we-could-do-better/


https://www.annemergmed.com/article/S0196-0644(19)30448-2/pdf


https://www.east.org/education-resources/practice-management-guidelines/details/emergency-department-thoracotomy-in-children-a-pts-wta-and-east-systematic-review-and-practice-manag


https://journals.lww.com/jtrauma/abstract/2023/09000/emergency_department_thoracotomy_in_children__a.21.aspx


https://nycremsco.org/wp-content/uploads/2024/07/2024-REMAC-Unified-Prehospital-Protocols-2024-01-004.pdf


https://umem.org/educational_pearls/4743/

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