Boerhaave Syndrome

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Boerhaave Syndrome

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Boerhaave syndrome
-DDx includes: Acute aortic dissection,  variceal hemorrhage, acute pancreatitis, myocardial infarction, and pneumothorax.
-Precipitants include iatrogenic vs spontaneous vs traumatic.
-CXR revealed mediastinal or free peritoneal air or subcutaneous emphysema, CT scan of the chest/abdomen + contrast esophagogram (Gastrografin/water-soluble contrast) ordered.  Revealed XXXX. Determine if free or contained perforation.
-Admit to ICU.
-Monitoring ABC, will intubate if airway compromise/ for airway protection.
-Strict NPO, consider parenteral nutrition, and avoid blood thinners.
-Ordered 2 large-bore peripheral IV or central venous catheter.
-Will start IV fluid resuscitation.
-Obtain CBC, CMP, lactate, ammonia, lipase, PT/INR, PTT, blood cultures, troponin, and EKG.
-Typed and screen/cross match.
-Monitor hemoglobin q4, transfuse as needed.
-Start broad spectrum antibiotics, Zosyn and Vancomycin.
-Start IV proton pump inhibitor (pantoprazole 80mg IV); will start IV octreotide (octreotide 50 mcg IV bolus, followed by 50 mcg/hour continuous IV infusion), if patient has history of cirrhosis.
-Consult gastroenterologist/ general surgery/ interventional radiology; NG tube insertion vs endoscopic therapy with stent placement +/- pleural drainage (for poor surgical candidates) vs surgical intervention.
-Will require VATS with fundic reinforcement. Discuss with specialist. 
-Will monitor for mediastinitis, emphysema, and necrosis. Monitor for shock.  
-Prognosis guarded, up to 50% mortality.

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