314 Emergency Medicine
patients have mediastinal or cervical emphysema,which may be noted by
palpation or by a crunching soundheard during auscultation (ie, Hamman
sign).An immediate esophagram with a water-soluble agent (eg, Gastrografin)
is indicated.
(a)Bronchoscopy is used to evaluate a patient with suspected bronchial
obstruction or endobronchial disease. It is not indicated in a case of suspected
esophageal perforation. (b)The likelihood that this patient’s chest pain is
cardiac in origin is fairly small and the ECG demonstrates no ischemic
changes. The diagnosis in a patient presenting with pain or fever following
esophageal instrumentation should be considered esophageal perforation
until proven otherwise. Also, if perforation is suspected, aspirin should be
withheld.(c)Repeating the endoscopy may be useful, especially in cases of
trauma; however, small perforations may be difficult or impossible to detect.
An esophagram is better to evaluate for a suspected perforation. A chest radi-
ograph and an upright abdominal radiograph are usually obtained first, and
may detect abnormalities in up to 90% of patients. These findings may include
subcutaneous emphysema, pneumomediastinum, mediastinal widening,
pleural effusion, or pulmonary infiltrate, but radiographic changes may not
be present in the first few hours after the perforation. (d)Thoracotomy is the
treatment for an esophageal perforation; however, an immediate esophagram
with a water-soluble agent should be performed to confirm the diagnosis.
288.The answer is b.(Tintinalli, pp 536-538.)The diagnosis of diverticulitis
is made by abdominal CT, which may demonstrate inflammation of pericolic
fat, bowel wall thickening, the presence of diverticula, or peridiverticular
abscess. The treatment of diverticulitis includes IV hydration, bowel rest,
and broad-spectrum antibioticsto cover both aerobic and anaerobic bacteria.
These typically include a combination of metronidazole and ciprofloxacin
or levofloxacin. Well-appearing patients can be treated as outpatients with
oral antibiotics and close follow-up, but patients with fever, signs of localized
peritonitis or obstruction, and those who have failed outpatient therapy
must be admitted to the hospital.
(a)This patient has systemic signs of infection (fever, rebound tenderness,
guarding) and should be admitted for IV antibiotics and observation. If the
patient manifests signs of bowel obstruction, a NG tube should also be
placed.(c)The presentation of diverticulitis may be indistinguishable from
acute appendicitis. This occurs when a patient has a redundant sigmoid
lying on the right side of the abdomen or, as in this case, when a cecal
diverticulum becomes inflamed. In this case, the abdominal CT demonstrates