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

EMS Medical Terminology - Eponymous Conditions

EMS Providers should be aware of the origins of eponymous medical conditions and equipment names because understanding the history and context behind these terms helps them provide better patient care and communicate effectively with other medical professionals. 

Here are some key points EMS providers should know about the origins and significance of eponymous medical terms:

1. Historical Context:

Eponyms Reflect Medical Discovery: Many medical conditions and equipment are named after pioneers who either discovered the disease or developed essential medical tools. This gives EMS providers insight into the historical development of medical knowledge and practices.

Example: Beck's Triad, named after Claude Beck, describes signs of cardiac tamponade — hypotension, muffled heart sounds, and jugular vein distention — and knowing its origins can help in quick recognition of life-threatening situations.

2. Eponyms and Recognition of Disease Characteristics:

Conditions Named After Patients: Some diseases are named after the first patients or well-known individuals who had the condition, which helps in recognizing patterns of disease progression.

Example: Lou Gehrig’s Disease is a common name for amyotrophic lateral sclerosis (ALS), which became widely known when Lou Gehrig, a famous baseball player, was diagnosed with it. This eponym raises awareness of the disease’s progression and its neurodegenerative impact.

3. Impact on Communication:

Universal Understanding Across Disciplines: Eponyms serve as a universal language among healthcare providers. Even though the underlying mechanisms or treatments may evolve, using an eponym ensures that providers understand exactly what condition or tool is being referenced.

Example: APGAR Score, named after Dr. Virginia Apgar, is a quick assessment used globally to evaluate newborns immediately after birth. EMS providers can use this term to quickly communicate newborn health status to receiving hospitals.

4. Recognizing Outdated Eponyms:

Evolving Terminology: Over time, some eponyms become less frequently used, especially when new understanding or discoveries provide more precise descriptors. However, EMS providers may still encounter outdated eponyms and should recognize them.

Example: Bright’s Disease was historically used to describe a variety of kidney diseases, now recognized under more specific conditions such as nephritis or glomerulonephritis.

5. Eponyms in Medical Equipment:

Tools Named After Inventors: Certain medical tools and devices are named after their inventors, and understanding these origins can enhance the provider's appreciation for the tool’s function and use in the field.

Example: The Guedel airway, an oropharyngeal airway, was named after Dr. Arthur Guedel, an anesthesiologist, and its usage is critical in managing airway obstruction in unconscious patients.

6. Cultural Sensitivity:

Controversies Around Some Eponyms: Some eponyms are tied to individuals whose contributions to medicine are controversial due to ethical issues. Understanding these backgrounds can help EMS providers navigate discussions sensitively.

Example: The Heimlich Maneuver, named after Dr. Henry Heimlich, was widely taught for choking emergencies but later became controversial as newer techniques were developed.

7. Common Eponyms in EMS:

EMS providers frequently encounter eponyms during patient care or when communicating with other medical professionals. Familiarity with these terms aids in recognizing critical conditions and providing timely interventions.

• Kernig’s Sign: An indicator of meningitis.

• Murphy’s Sign: Associated with gallbladder disease.

• Cushing's Reflex: Indicates increased intracranial pressure.

Conclusion

EMS providers should understand the origins of eponymous medical terms and equipment to improve communication, recognize critical conditions, and appreciate the historical context behind these essential medical terms. 

This knowledge adds depth to their practice and ensures accurate patient care.

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

Ebright, C. (2024) Unique Patient Signs: A Case Study. EMS1. Accessed May 1, 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