EMS Medical Terminology - Mallory-Weiss Syndrome

Mallory-Weiss Syndrome is a condition characterized by a tear in the mucous membrane of the lower esophagus or upper stomach, typically caused by severe vomiting or retching. It is an example of an eponymous medical term.

Mallory-Weiss Syndrome was first described in 1929 by George Kenneth Mallory and Soma Weiss, two American physicians at Boston City Hospital. They documented the condition in patients who had experienced upper GI bleeding following severe vomiting. 

Their work highlighted the mucosal tears at the gastroesophageal junction and led to the eponymous naming of the syndrome.

Unlike Boerhaave Syndrome, where the esophagus ruptures completely, Mallory-Weiss Syndrome involves only a partial tear of the mucosal layer. 

This condition is associated with upper gastrointestinal (GI) bleeding and is often self-limiting but can occasionally lead to significant hemorrhage.

Causes and Pathophysiology

Triggered by Severe Vomiting: The syndrome often occurs after repeated vomiting or retching episodes, usually related to alcohol intoxication, eating disorders, or acute gastroenteritis.

Other Causes: Coughing, lifting heavy objects, trauma, convulsions, or anything that increases intra-abdominal pressure.

Pathophysiology: The increased pressure from vomiting causes a longitudinal tear at the gastroesophageal junction, leading to bleeding.

Signs and Symptoms

Patients with Mallory-Weiss syndrome may present with:

• Hematemesis: Vomiting of bright red blood or "coffee-ground" emesis. A hallmark symptom.
• Melena: Black, tarry stools due to digested blood.
• Epigastric or Retrosternal Pain: Pain located in the upper abdomen or chest, which may be mistaken for other conditions like myocardial infarction.
• Signs of Hypovolemia: If bleeding is severe, look for signs such as dizziness, hypotension, pallor, and tachycardia.
• History of Severe Vomiting: Often after binge drinking or an illness causing repeated retching.

EMS Recognition and Prehospital Treatment

Patient Assessment Priorities:

• History Taking: Ask about recent vomiting, alcohol use, or illnesses that might have led to repeated retching.

Inquire about the color and amount of vomitus. Bright red blood is more suggestive of active bleeding, while coffee-ground emesis suggests older blood.

Determine any history of GI bleeding or relevant medical conditions (e.g., peptic ulcer disease, cirrhosis).

• Physical Examination: Assess for signs of hypovolemic shock: tachycardia, hypotension, altered mental status, and pallor.

Perform an abdominal exam to check for tenderness, guarding, or distension.

Check for melena, if possible.

• Differential Diagnosis: Always differentiate MWS from other causes of hematemesis or epigastric pain:

• Peptic Ulcer Disease
• Esophageal Varices (often linked to liver disease)
• Gastric Ulcers or Malignancies
• Boerhaave Syndrome

Patient Management Priorities:

• Airway Management: Ensure the airway is clear. Patients actively vomiting blood are at risk of aspiration.

Position the patient to prevent aspiration (e.g., left lateral recumbent position).

• Circulatory Support: Establish IV access and administer IV fluids (normal saline or lactated Ringer’s) if the patient shows signs of shock.

Monitor for worsening hemodynamic instability.

• Minimize Further Trauma: Advise the patient to avoid any further vomiting, coughing, or retching as it can exacerbate the tear.

Keep the patient NPO (nothing by mouth) to prevent further irritation.

Treat Nausea and Vomiting: If protocols allow, consider administering antiemetics (e.g., ondansetron) via IV to prevent further vomiting, which could worsen the tear.

• Oxygen Therapy: Administer oxygen if the patient has signs of hypoxemia or shock.

• Monitor: Continuously monitor vital signs, including heart rate, blood pressure, and mental status.

• Rapid Transport: Rapid transport to a hospital with endoscopy capabilities is crucial, as definitive diagnosis and management (e.g., endoscopic hemostasis) often require specialist care.

Key Considerations for EMS

• Monitor for Signs of Shock: Patients can quickly decompensate, especially if bleeding is significant.

• Avoid Overly Aggressive Fluid Resuscitation: While fluids are necessary to stabilize blood pressure, overloading can increase bleeding.

• Rapid Transport to Definitive Care: Most Mallory-Weiss tears are diagnosed and treated via endoscopy.

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.

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

Rawla, P., Devasahayam, J. (2023) Mallory-Weiss Syndrome. StatPearls  Treasure Island, Florida: StatPearls. Accessed September 20, 2024

Turner, A. R., Collier, S. A., & Turner, S. D. (2023) Boerhaave Syndrome. Treasure Island, Florida: StatPearls. Accessed September 14, 2024

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 Medical Terminology - Mackler’s Triad

Mackler’s Triad is a clinical diagnostic tool associated with spontaneous esophageal rupture, also known as Boerhaave Syndrome. It is an example of an eponymous medical term.

It includes three key symptoms:

• Vomiting: Usually forceful and occurs before the rupture.

• Sudden Onset Chest Pain: Sudden onset after vomiting.

• Subcutaneous Emphysema: Air trapped under the skin, often detected around the neck or chest, creating a crackling sensation upon palpation (due to air leaking from the esophagus).

EMS providers should be aware that Boerhaave Syndrome is a life-threatening condition that requires immediate medical intervention. 

Early recognition of the symptoms in Mackler’s Triad is critical, as delayed diagnosis and treatment significantly increase the risk of morbidity and mortality.

Key Points for EMS Providers:

High Suspicion Following Forceful Vomiting: If a patient presents with intense chest pain after vomiting, suspect an esophageal rupture.

Subcutaneous Emphysema: Feel for air under the skin, especially in the neck and chest areas.

Need For Rapid Transport: Esophageal ruptures require surgical intervention and antibiotics to prevent fatal infections such as mediastinitis (infection in the chest cavity).

Stabilization: Manage the airway, ensure the patient is NPO (nothing by mouth), administer IV fluids if necessary, and provide pain control.

Who Discovered This?

Dr. Sydney S. Mackler was an American physician and surgeon who first described the triad in 1952. He made significant contributions to understanding and diagnosing Boerhaave Syndrome. 

The triad is named after him due to his work linking these three symptoms to spontaneous esophageal rupture, helping to guide clinicians in making this often elusive diagnosis.

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

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