A case study: Boerhaave's syndrome.

JG was a 50-year-old man who had been having epigastric pain and shortness of breath for 2 or 3 days, which he attributed to his history of gastritis and self-treated with antacids. He had several episodes of vomiting but did not note any blood in the emesis. Four hours after awakening with continued sharp right upper quadrant pain, chest pain, worsening dizziness, difficulty breathing, and general malaise, he called 9-1-1. Emergency medical service personnel found him awake and fully oriented, with respiratory rate of 40 breaths per minute, wheezing in both lung fields, and cool, clammy skin. His heart rate was 120 beats per minute with no obtainable blood pressure or pulse oximetry waveform from a probe placed on his fingertip. Intravenous therapy with 900-mL crystalloid bolus and albuterol nebulizer treatment were completed during transport to the local emergency department (ED). On arrival at the community hospital, JG’s initial vital signs were heart rate 126 beats per minute, blood pressure 119/66 mm Hg, respiratory rate 38 breaths per minute, SpO2 92% on room air, and temperature 96.8° F. Additional large bore intravenous access was secured because the staff noted the patient’s skin to be “clammy and mottled.” ED workup included arterial blood gas analysis, chest x-ray, and continued intravenous crystalloid resuscitation. The differential diagnosis was listed as “acute surgical abdomen” by the ED attending and consulting general surgeon. Foley and nasogastric tubes were placed while waiting for the lab results to return. JG’s initial arterial blood gas was reported as pH 7.23, PCO2 24 mm Hg, PO2 72 mm Hg, HCO3 10 meq/L, and base excess (BE) -15.9 The x-ray film showed bilateral pleural effusions, with the worst being on the left. A left tube thoracostomy was performed with a 28-French chest tube. Immediately 1100 mL of a brown fluid drained into the chest drainage unit. Symptoms of shortness of breath continued, as did oxygen saturations of 89% on room air and 93% on 2 L by nasal cannula (NC). He was set up for a contrasted abdominal/chest computed tomography (CT) scan and given oral contrast mixed with methylene blue. After the CT scan, his chest drainage unit contained blue pleural fluid. His blood pressure dropped precipitously to 66/39, heart rate 124 beats per minute, and O2 saturation down to 89% on 2 L NC. While the intravenous fluids were opened wide, arrangements were made to transfer him to Virginia Commonwealth University Health System for evaluation by the cardiothoracic surgical services. The time from arrival in the ED to the transfer request totaled 6 hours. When the air medical crew arrived, JG was normotensive but remained tachycardic and tachypneic. He had received a total of 5 L crystalloid and remained on an NC at 4 L. He was anxious, mucous membranes were dry and cracked, and skin was cool and moist. Review of the 12-lead electrocardiogram revealed only sinus tachycardia with no acute changes. Abdominal assessment revealed a firm abdomen with pain rated 10 on a 10-point scale. Intravenous fluids remained wide open, so the patient was placed on nonrebreather 100% oxygen and rapidly packaged for transport. While loading into the helicopter, JG’s anxiety and work of breathing increased. Once he was secure, the flight crew per-