Dissanaike Sharmila, Shalhub Sherene, Jurkovich Gregory J
Division of Trauma and Critical Care Surgery, Harborview Medical Center, University of Washington, Seattle, Washington 98104, USA.
J Trauma. 2008 Dec;65(6):1340-5. doi: 10.1097/TA.0b013e318169cd24.
Pneumomediastinum occurs in up to 10% of patients with blunt thoracic and cervical trauma. Mandatory evaluation of all patients with bronchoscopy and esophageal imaging to exclude a major injury has been recommended. There is little data on the safety or efficacy of this approach. We evaluated the incidence of major injuries associated with pneumomediastinum, the accuracy of diagnostic modalities, and the results of observation versus aggressive evaluation.
Medical records of all blunt trauma patients diagnosed with pneumomediastinum and/or aerodigestive tract injury between 1998 and 2005 were reviewed. The patient's hospital course was reviewed for demographic data, admission diagnoses, diagnostic imaging and procedures, operations, missed injuries, length of stay, and mortality.
The review identified a total of 136 patients with pneumomediastinum, and an additional 22 patients with thoracic aerodigestive tract injuries but without pneumomediastinum. Only patients with pneumomediastinum were considered in subsequent analysis. Pneumomediastinum was detected by CT scan in all 136 (100%) patients, although identified on plain radiograph in only 20 (15%) patients. Computed tomography findings were suspicious for a major aerodigestive tract injury in 27 (20%) patients. Ten (37%) of these 27 patients had an injury requiring operative intervention: five (4%) laryngeal injuries, three (2%) tracheal disruptions, and two (1%) esophageal perforations. Eighty-one patients (60%) never had endoscopic evaluation. There were no delayed diagnoses, missed injuries, or complications in the observation-only cohort. The overall sensitivity and specificity of CT scan for major aerodigestive tract injury was 100% and 85%, respectively.
Major airway or esophageal injury is an uncommon cause of pneumomediastinum. CT scan was able to identify patients at high risk for aerodigestive injury in all cases, and should be the preferred screening tool for airway injury in patients with pneumomediastinum.
纵隔气肿在高达10%的钝性胸颈部创伤患者中出现。已建议对所有患者进行支气管镜检查和食管成像的强制性评估，以排除重大损伤。关于这种方法的安全性或有效性的数据很少。我们评估了与纵隔气肿相关的重大损伤的发生率、诊断方法的准确性以及观察与积极评估的结果。
回顾了1998年至2005年间所有诊断为纵隔气肿和/或气消化道损伤的钝性创伤患者的病历。审查了患者的住院病程，包括人口统计学数据、入院诊断、诊断性影像学检查和操作、手术、漏诊损伤、住院时间和死亡率。
该回顾共确定了136例纵隔气肿患者，另外22例胸段气消化道损伤但无纵隔气肿的患者。后续分析仅考虑纵隔气肿患者。所有136例（100%）患者均通过CT扫描检测到纵隔气肿，尽管仅20例（15%）患者在X线平片上被发现。27例（20%）患者的CT表现怀疑有重大气消化道损伤。这27例患者中有10例（37%）有需要手术干预的损伤：5例（4%）喉部损伤、3例（2%）气管破裂和2例（1%）食管穿孔。81例（60%）患者从未接受过内镜评估。仅观察队列中没有延迟诊断、漏诊损伤或并发症。CT扫描对重大气消化道损伤的总体敏感性和特异性分别为100%和85%。
大气道或食管损伤是纵隔气肿的罕见原因。CT扫描能够在所有病例中识别出气消化道损伤高危患者，应成为纵隔气肿患者气道损伤的首选筛查工具。
