Boerhaave Syndrome is a spontaneous rupture of the esophagus, typically caused by a sudden increase in intraesophageal pressure.
Boerhaave Syndrome is named after the Dutch physician Herman Boerhaave (1668–1738), who first described the condition in 1724. He documented it after performing an autopsy on Baron Jan van Wassenaer, a Dutch admiral who died suddenly after forcefully vomiting following a large meal.
It is a life-threatening condition that often results from severe retching or vomiting, but it can also be triggered by activities like heavy lifting, coughing, or convulsions.
Boerhaave observed that the rupture of the esophagus was due to a sudden increase in intraesophageal pressure caused by violent vomiting. His detailed documentation of the case provided the first description of spontaneous esophageal rupture, making it a significant discovery in medical history.
As a result, the syndrome bears his name to honor his contribution to understanding this rare but deadly condition. It is an example of an eponymous medical term.
Rapid identification, using a clinical diagnostic tool such as Mackler’s Triad, and treatment are crucial, as this condition carries a high mortality rate if left untreated.
Causes and Pathophysiology
Commonly Triggered by Severe Vomiting: Often occurs after a bout of forceful vomiting or retching.
Other Causes: Can occur due to trauma, childbirth, seizures, or endoscopic procedures.
Pathophysiology: The abrupt increase in pressure within the esophagus causes a tear, leading to the leakage of gastric contents into the mediastinum, which can cause mediastinitis, sepsis, and shock.
Signs and Symptoms to Recognize
Mackler’s Triad of symptoms is a strong diagnostic indicator of Boerhaave Syndrome:
• Vomiting: Often described as severe and forceful, preceding the rupture.
• Sudden Onset Chest Pain: May radiate to the back, neck, or shoulders, and can be mistaken for myocardial infarction (MI) or other thoracic emergencies.
• Subcutaneous Emphysema: A crackling sensation felt under the skin, typically around the neck or upper chest, due to air escaping from the ruptured esophagus.
This can also present as a crunching sound (Hamman's Sign) on auscultation of the chest, especially with each heartbeat.
Other Symptoms Can Include:
- Dysphagia - Difficulty Swallowing
- Dyspnea - Shortness of Breath
- Tachypnea - Rapid breathing
- Cyanosis
- Hypotension
- Signs of Shock in Severe Cases
EMS Assessment and Management
When evaluating a patient with suspected Boerhaave Syndrome, EMS providers are advised to:
- Assess the History of Events Leading Up to the Pain:
- Determine if there was a history of severe vomiting or retching.
- Ask about recent alcohol consumption, as it’s a common predisposing factor.
- Focused Physical Examination:
- Palpate the neck and upper chest for subcutaneous emphysema.
- Auscultate for Hamman’s Sign (e.g., a crunching sound synchronous with the heartbeat).
- Assess for signs of shock (e.g., hypotension, altered mental status, pallor, diaphoresis).
- Differential Diagnosis Considerations:
Boerhaave Syndrome can be mistaken for other critical conditions, such as acute myocardial infarction, aortic dissection, pulmonary embolism, or peptic ulcer perforation.
Always consider Boerhaave Syndrome in a patient with recent vomiting and acute chest pain.
Patient Management Priorities:
- ABC Assessment: Ensure the airway is secure, provide oxygen as needed, and monitor for respiratory distress.
- Positioning: Place the patient in a position of comfort to minimize pain.
- Pain Control: Use opioids with caution as they can cause vomiting. Consider antiemetic medications, if protocols allow.
- Establish IV Access: For fluid resuscitation if signs of shock are present.
- NPO (Nothing by Mouth): Avoid giving the patient anything by mouth to prevent further esophageal damage.
- Rapid Transport: Esophageal rupture requires surgical repair, so immediate transport to a facility capable of managing thoracic emergencies is critical.
Key Takeaways for EMS Providers
• Recognize the Signs: Remember Mackler’s Triad—vomiting, chest pain, and subcutaneous emphysema.
• Differentiate from Other Thoracic Emergencies: The presentation can mimic more common conditions like MI, but the history of vomiting and presence of subcutaneous emphysema should raise suspicion for Boerhaave syndrome.
• Act Fast: Time is critical. The sooner the patient is evaluated and treated, the better the outcome.
• Minimize Esophageal Trauma: Avoid oral intubation if possible and keep the patient NPO to prevent aggravating the tear.
Early recognition and transport to definitive care are the most critical roles EMS can play in the management of Boerhaave Syndrome.
Further Reading:
Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education
Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson
Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.
Loftus, I. A., Umana, E. E., Scholtz, I. P., & McElwee D. (2023) Mackler's Triad: An Evolving Case of Boerhaave Syndrome in the Emergency Department. Cureus 15 (4): e37978. Accessed September 16, 2024
Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education
Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell
Turner, A. R., Collier, S. A., & Turner, S. D. (2023) Boerhaave Syndrome. Treasure Island, Florida: StatPearls. Accessed September 14, 2024
