EMS Medical Terminology - Boerhaave Syndrome

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

EMS Cardiac Emergencies - Pericarditis

Overview

Pericarditis is the inflammation of the pericardium, the protective sac around the heart. For EMS providers, recognizing pericarditis is critical because it can lead to serious complications like pericardial effusion or cardiac tamponade. 

The condition can be caused by a range of factors, including viral infections, bacterial infections, autoimmune disorders like lupus, trauma, and certain medications. 

It may also occur after a myocardial infarction (post-MI pericarditis or Dressler's Syndrome) or be associated with cancer or renal failure. Understanding the causes can help guide treatment and determine how urgent the patient’s condition may be.

Here are some things an EMS Provider needs to know:

Signs and Symptoms

Patients with pericarditis typically present with chest pain that is sharp, stabbing, and pleuritic in nature, meaning it worsens with deep breaths or coughing. A distinguishing feature of pericarditis-related chest pain is that it often improves when the patient sits up and leans forward, and worsens when lying flat. The pain can radiate to the neck, shoulders, or back, which can sometimes mimic the pain of a myocardial infarction.

In addition to chest pain, fever may be present, especially in cases caused by infections. Patients might also experience dyspnea, particularly if pericardial effusion (fluid buildup around the heart) develops. 

A classic sign detectable on physical examination is a pericardial friction rub, a scratchy or grating sound heard with a stethoscope near the left sternal border. 

EMS Providers may notice widespread ST-segment elevation across multiple leads and PR-segment depression on an EKG, both of which are characteristic of pericarditis. 

These combined symptoms can help differentiate pericarditis from other cardiac conditions, such as myocardial infarction.

Prehospital Treatment

Prehospital care for pericarditis focuses on symptom management and preventing complications. Positioning the patient in an upright or leaning-forward posture can relieve pain, and oxygen should be administered if hypoxia or dyspnea is present. 

NSAIDs, such as aspirin, if within protocol, can be used to alleviate pain and reduce inflammation. 

EKG monitoring is essential to detect any potential changes, such as arrhythmias or signs of tamponade. 

Providers should establish IV access for medications or fluid resuscitation, and if cardiac tamponade is suspected (marked by hypotension, jugular venous distention, and muffled heart sounds a.k.a Beck's Triad), rapid transport to a hospital is critical. 

Early hospital notification can prepare the receiving facility for advanced care.

In-Hospital Treatment

Once in the hospital, patients with pericarditis will undergo diagnostic testing, including an EKG to assess for pericardial effusion, and other tests such as chest X-rays or bloodwork to identify the underlying cause. 

Treatment usually involves anti-inflammatory medications like NSAIDs or colchicine to reduce inflammation and prevent recurrence. In some cases, corticosteroids may be used, but they are typically reserved for autoimmune cases or refractory pericarditis. 

Antibiotics are administered if a bacterial infection is identified. If a large pericardial effusion or cardiac tamponade is detected, emergency pericardiocentesis (draining fluid from the pericardium) is necessary. 

For recurrent or chronic pericarditis, surgical intervention, such as a pericardiectomy, might be considered.

Key Takeaways for EMS Providers

EMS Providers should be able to recognize pericarditis through its hallmark symptoms, including sharp, pleuritic chest pain and characteristic ECG changes. 

Rapid identification and intervention can prevent complications such as cardiac tamponade.

Prehospital care should focus on pain management, patient positioning, and continuous cardiac monitoring, while maintaining a high index of suspicion for worsening conditions. 

Prompt transport to a facility equipped for advanced cardiac care is essential, where definitive treatments, such as anti-inflammatory medications or pericardiocentesis, can be administered. Early intervention and effective prehospital management play a key role in patient outcomes.

Further Reading:

Ari D. Leib; Lisa A. Foris; Tran Nguyen; Karam Khaddour (2023) Dressler Syndrome. Treasure Island, Florida: StatPearls Publishing  Accessed September 7, 2024

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson.

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell.

Xanthopoulos, A. & Skoularigis, J. (2017) Diagnosis of Acute Pericarditis. Journal of Cardiology Practice #15. Accessed September 6, 2024