01Approach to the Critical Patient/attcp56

Immediate priorities

›Airway and breathing threats

›Respiratory failure risk

›Dyspnea from mediastinal compression

›Pleural effusion causing hypoxia

›Hemodynamic collapse risk

›Septic shock from mediastinal contamination

›Distributive physiology from chemical mediastinitis

›If airway compromise, proceed to definitive airway immediately

›Avoid blind nasogastric tube placement

›Endoscopic guidance for NG if needed

›Resuscitation priorities

›Large-bore IV access x2

›Aggressive crystalloid resuscitation

›Target MAP >= 65 mmHg

›NPO immediately on suspicion

›No oral medications

›Nil per os enforced

›Broad-spectrum antibiotics within 1 hour of suspected diagnosis

›Piperacillin-tazobactam 4.5 g IV q6h first-line

›Meropenem if high resistance risk or allergy

›IV proton pump inhibitor initiation

›Pantoprazole 40 mg IV

›Reduces acid exposure at perforation site

Monitoring and targets

›Monitoring bundle

›Continuous cardiac monitoring

›Tachycardia as earliest sepsis sign

02History/hx71

Presentation pattern

›Classic symptom triad (Mackler triad)

›Forceful vomiting or retching

›Often alcohol-related binge

›Post-anesthesia vomiting

›Severe chest or epigastric pain

›Sudden onset, pleuritic character

›Radiation to back or left shoulder

›Subcutaneous cervical emphysema

›Pathognomonic but present in minority

›Palpable crepitus in neck or chest wall

›Atypical presentations

›Isolated back pain

›Mimics aortic dissection or pancreatitis

›No chest pain reported in subset

›Isolated epigastric pain

›Mimics peptic ulcer perforation

›Mimics acute pancreatitis

›Delayed presentation

›Sepsis and mediastinitis without clear history

›Diagnosis delayed in >50% of cases

Risk factors

›Precipitating events

›Forceful vomiting (spontaneous Boerhaave)

›Alcohol binge commonest precipitant

›Hyperemesis gravidarum

›Iatrogenic instrumentation

›EGD, esophageal dilation, stent placement

03Physical Exam/exam49

Vital signs

›Hemodynamic assessment

›Tachycardia

›Earliest and most reliable finding

›HR >100 bpm in majority

›Hypotension

›Late and ominous finding

›SBP <90 mmHg suggests septic shock

›Fever

›Often absent in first few hours

›High fever with rigors indicates mediastinitis

›Tachypnea

›RR >20/min from pain or effusion

›Severe tachypnea from tension physiology

Head, neck, and chest exam

›Neck findings

›Subcutaneous emphysema

›Palpable crepitus over neck or clavicles

›Present in ~60% of cervical perforations

›Only ~33% of thoracic perforations

›Neck swelling

›Suggests cervical perforation

›Voice changes from cervical air

›Chest findings

›Hamman's sign

›Mediastinal crunch synchronous with heartbeat

›Auscultated over precordium

›Suggests pneumomediastinum

04Differential Diagnosis/ddx43

Life-threatening mimics

›Cardiovascular emergencies

›Acute coronary syndrome

›ICD-10 I24.9

›ECG and troponin differentiate

›Aortic dissection

›ICD-10 I71.01

›CT angiography differentiates

›Tearing pain to back

›Thoracic emergencies

›Tension pneumothorax

›ICD-10 J93.0

›Tracheal deviation, absent breath sounds

›Needle decompression required

›Pulmonary embolism

›ICD-10 I26.99

›Pleuritic pain, hypoxia, tachycardia

›CT pulmonary angiogram differentiates

›Abdominal emergencies

›Perforated peptic ulcer

›ICD-10 K27.1

›Free air under diaphragm on plain film

›Board-like rigidity

›Acute pancreatitis

›ICD-10 K85.90

›Elevated lipase differentiates

›Epigastric radiation to back

05Laboratory Tests/lt45

Core inflammatory and metabolic labs

›Infection and inflammation panel

›Complete blood count

›Leukocytosis (nonspecific, inflammatory response)

›Leukopenia as severe sepsis marker

›C-reactive protein

›Elevated but nonspecific

›Trend useful for monitoring

›Procalcitonin

›Bacterial infection support

›Not diagnostic alone

›Renal and metabolic panel

›Electrolytes and creatinine

›Antibiotic dosing adjustment

›Dehydration from vomiting

›Liver function tests

›Sepsis-associated cholestasis

›Drug metabolism considerations

Perfusion and sepsis labs

›Lactate

›>= 2 mmol/l indicates hypoperfusion

›>= 4 mmol/l criteria for septic shock

›Repeat within 2 hours if elevated

›Blood cultures

›Obtain before antibiotics when feasible

›Two sets from peripheral sites

›Gram-negative rods and anaerobes expected

›Arterial blood gas

06Diagnostic Tests/dt73

Scoring Systems

›Pittsburgh Esophageal Perforation Severity Score (PSS)

›10-variable validated scoring system

›Clinical and radiological parameters combined

›Age, comorbidities, cause, delay, CT findings

›Score interpretation

›Score <=2: may be eligible for nonoperative management

›Score 3-5: intermediate risk

›Score >5: high risk, 3.37x more likely to require surgery

›Validated across multinational cohort studies

›Published in Journal of Thoracic and Cardiovascular Surgery 2016

›Guides treatment pathway selection

›AAST Esophagus Injury Scale

›Grades I through V classification

›Grade I: contusion or hematoma

›Grade III-V: full-thickness perforation to devascularization

›Trauma context primarily

›Applicable to iatrogenic and spontaneous injury grading

MRI

›MRI chest role

›Limited utility in acute esophageal perforation

›Availability constraints in emergency setting

›Motion artifact from pain and tachypnea

›Potential problem-solving indications

›Suspected malignancy underlying perforation

›Complex mediastinal anatomy post-treatment

›Contraindications in acute setting

›Unstable hemodynamic patient

07Disposition/dispo34

ICU admission (mandatory)

›All confirmed or suspected perforations require ICU admission

›Hemodynamic instability

›SBP <90 mmHg or MAP <65 mmHg

›Vasopressor requirement

›Sepsis physiology

›Lactate >= 2 mmol/l

›Signs of mediastinitis or empyema

›Surgical or endoscopic intervention planning

›Post-procedure monitoring required

›Median ICU stay ~8 days

›Observation is not appropriate

›No observation-level pathway exists for this diagnosis

›Discharge from ED is contraindicated

Transfer criteria

›Immediate transfer if thoracic surgery unavailable

›Advanced esophageal endoscopy capability required

›Esophageal stenting expertise

›Endoscopic vacuum therapy expertise

›Tertiary center with esophageal surgery capability

›Stabilize before transfer if possible

›Do not delay transfer for definitive imaging if unstable

›Transfer considerations

›Antibiotics before transfer

›IV access and resuscitation ongoing

›Airway secured if any airway concern

In-hospital milestones

›Expected hospital course

08Treatment/t129

Immediate stabilization

›Initial ED management

›NPO strict enforcement

›No oral medications

›No oral contrast unless absolutely required

›IV fluid resuscitation

›Crystalloid 30 mL/kg bolus initially

›Reassess lactate and hemodynamics at 1 hour

›Airway management

›Avoid blind NG tube insertion

›If NG needed, endoscopic guidance preferred

›RSI preparation if airway compromised

Antibiotics

›First-line broad-spectrum coverage

›Piperacillin-tazobactam

›4.5 g IV every 6 hours

›Extended infusion per local protocol for severe sepsis

›Covers aerobic gram-negatives and anaerobes

›Ampicillin-sulbactam alternative

›3 g IV every 6 hours

›Renal dose adjustment required if impaired

›Carbapenem escalation

›Meropenem

›1 g IV every 8 hours

›Preferred in high resistance risk or polymicrobial sepsis

›2 g IV every 8 hours for extended-spectrum pathogens

›Imipenem-cilastatin alternative

›500 mg IV every 6 hours

›Seizure risk consideration in CNS disease

›Antifungal therapy

›Fluconazole 400 mg IV daily

›Indicated if chronic PPI use

›Indicated if immunosuppressed, HIV, chronic steroids

›Indicated if known esophageal candidiasis

›Duration guided by clinical response and cultures

Surgical management

›Primary surgical repair and drainage

›Cornerstone of definitive treatment

›Left posterolateral thoracotomy for distal perforation

›Two-layer closure of esophageal wall

›Mortality ~13% with surgical management

›Best outcomes when repair within 24 hours

›Late presentation increases morbidity significantly

›Mediastinal drainage mandatory

›Wide drainage of contaminated spaces

›Irrigation with saline

›Esophagectomy (reserved cases)

›Extensive esophageal necrosis

›Irreparable tissue destruction

›End-stage esophageal disease

›Underlying malignancy

›Esophageal cancer perforation

›Palliation or curative intent depending on stage

Endoscopic management

›Self-expanding metal stents (SEMS)

›Comparable survival to surgery in selected patients

›Higher re-intervention rate (OR 4.55 vs surgery)

›Best for early, contained perforations

›Indications

›Contained leak with minimal contamination

›High surgical risk patient

›No frank mediastinal infection

›Stent bridging to surgery

›Temporizing measure in unstable patient

›Allows resuscitation before definitive repair

›Endoscopic vacuum therapy (EVT)

›Multicenter experience published Gastrointestinal Endoscopy 2025

›Applied for Boerhaave syndrome

›Sponge placed at perforation site under endoscopic guidance

›Indications

›Transmural perforation with contained cavity

›Alternative to surgery in selected centers

›Escalation option after failed stenting

›Sponge changed every 3-5 days

›Until granulation tissue closes defect

›Repeat endoscopic assessment each change

›Endoscopic clipping

›Over-the-scope clip (OTSC) or through-the-scope clip

›Best for small (<2 cm) acute perforations

›High-volume endoscopy centers

›Less evidence for Boerhaave specifically

›More data for iatrogenic perforations

Nonoperative management

›Criteria for conservative approach

›Stable hemodynamics

›No sepsis or septic shock

›No mediastinal contamination on CT

›Contained perforation

›Local seal present on imaging

›No free leakage into pleural or peritoneal cavity

›Pittsburgh PSS <=2

›Low severity score supports nonoperative path

›Close monitoring mandatory

›Components of nonoperative management

›NPO and IV PPI

›Pantoprazole 40 mg IV every 12 hours

›Strict NPO for minimum 5-7 days

›Antibiotics as above (same regimens)

›Drainage of adjacent collections

›CT-guided or thoracoscopic drainage if collections form

›Repeat imaging at 48-72 hours

›Serial imaging

›CT chest at 48-72 hours to assess for progression

›Water-soluble esophagography at day 5-7

Nutritional support

›Enteral nutrition priority

›Nasojejunal feeding tube

›Placed under endoscopic or fluoroscopic guidance

›Bypasses perforation site

›Preferred over TPN if feasible

›Total parenteral nutrition (TPN) alternative

›When enteral access not achievable

›Central line required

›Infection risk monitoring

›Oral intake resumption

›Only after contrast study confirms no leak

›Water-soluble esophagography at day 5-7

›Liquid diet advance before solids

›Dietitian involvement mandatory

›Caloric targets for wound healing

›Protein optimization

Drainage procedures

›Pleural drainage

›Chest tube for empyema or large pleural effusion

›Large-bore tube preferred for infected collections

›Position guided by CT or ultrasound

›Video-assisted thoracoscopic surgery (VATS)

›Fibrinous or loculated effusion

›Combined with primary repair in selected cases

›Vasopressor therapy

›Norepinephrine first-line for septic shock

›Start at 0.1-0.2 mcg/kg/min

›Titrate to MAP >= 65 mmHg

›Vasopressin adjunct

›0.03-0.04 units/min fixed dose

›Added if norepinephrine requirements increasing

09Special Populations/sp62

Pregnancy

›Pregnancy-specific considerations

›Esophageal perforation extremely rare in pregnancy

›Hyperemesis gravidarum as precipitant

›Childbirth straining as precipitant

›Maternal hemodynamic instability prioritized

›Fetal wellbeing secondary to maternal stabilization

›Obstetric consultation mandatory

›Imaging approach in pregnancy

›CT chest with oral contrast indicated if diagnosis uncertain

›Benefits of diagnosis outweigh radiation risk

›Fetal shielding where feasible

›Avoid unnecessary imaging delay for radiation concern

›Missed diagnosis is more dangerous than radiation dose

›Antibiotic safety

›Piperacillin-tazobactam generally safe in pregnancy (Category B)

›Beta-lactams preferred class

›Avoid fluoroquinolones

›Fluconazole

›Single high dose associated with fetal risk

›Consult maternal-fetal medicine for antifungal selection

Geriatric

›Older adult features

›Atypical presentation common

›Absence of fever does not exclude perforation

›Delirium as presenting symptom in some

›Comorbidity burden increases operative risk

›Pittsburgh PSS higher in geriatric patients

10Background/b69

Epidemiology

›Incidence and population data

›Rare but highly lethal condition

›Estimated 1-4 per 1,000,000 per year

›Most lethal gastrointestinal perforation

›Demographics

›Male predominance 70-78%

›Peak age 50-70 years

›Etiology distribution

›Iatrogenic causes ~50% of all esophageal perforations

›Spontaneous Boerhaave less common but highest mortality

›Mortality data

›Overall 90-day mortality ~12-19%

›Treatment within 24 hours: mortality ~7%

›Treatment delayed >48 hours: mortality 40-60%

›Diagnosis delayed in >50% of cases

›High index of suspicion essential

›Atypical presentations confound early recognition

Pathophysiology

›Mechanism of injury

›Sudden increase in intraesophageal pressure

›Exceeds tensile strength of esophageal wall

›Glottis closed during forceful vomiting (Valsalva)

›Location of perforation

›Left posterolateral distal esophagus most common (90%)

›2-3 cm above gastroesophageal junction

›Thinnest point, no external reinforcement

›Progression of mediastinal injury

11Patient Discharge Instructions/pdi33

copy discharge instructions

›Post-esophageal perforation home care (after hospital discharge)

›Diet and swallowing

›Follow the diet stage prescribed by your surgical team

›Soft or liquid diet initially, advance only as directed

›No hard, sharp, or large food pieces

›Chew all food thoroughly

›Activity restrictions

›No heavy lifting or strenuous activity until cleared by surgeon

›Gradually increase walking each day

›Medications

›Take all prescribed antibiotics until the course is finished

›Continue acid-reducing medication as prescribed

›Do not take any new medications without asking your doctor

›Warning signs — return to ER immediately

›Chest pain or new severe back pain

›Difficulty or painful swallowing (new or worsening)

›Fever above 38.5 C (101.3 F)

›Shortness of breath or rapid breathing

›Vomiting blood or material that looks like coffee grounds

›Neck swelling or a crackling feeling under the skin

›Feeling faint, dizzy, or collapsing

›Signs of infection at any wound or drain site (redness, pus, warmth)

›Follow-up plan

›Thoracic surgery appointment within 1-2 weeks of discharge

›Gastroenterology follow-up if endoscopic management was used

›Repeat swallowing X-ray or endoscopy as scheduled by your team

›Nutritional dietitian review if weight loss or poor appetite

12References/r35

Guidelines and key sources

›Society guidelines

›WSES Esophageal Emergencies Guidelines 2019 (Chirica et al.)

›World Journal of Emergency Surgery

›CT esophagography as first-line imaging

›Multidisciplinary management framework

›WSES Oesophageal Injuries Position Paper 2014 (Ivatury et al.)

›Diagnostic and treatment algorithm

›World Journal of Emergency Surgery

›Key clinical studies

›Schweigert M et al. Pittsburgh PSS multinational validation 2016

›Journal of Thoracic and Cardiovascular Surgery

›PSS score guides operative vs nonoperative decision

›Hauge T et al. Boerhaave treatment strategies 2025

›British Journal of Surgery

›Multinational retrospective cohort

›Reback T et al. Surgical vs endoscopic Boerhaave 2026

›Annals of the Royal College of Surgeons of England

›No mortality difference in selected patients

›Wannhoff A et al. Endoscopic vacuum therapy Boerhaave 2025

›Gastrointestinal Endoscopy

›Multicenter analysis of EVT outcomes

›DeVivo A et al. High Risk Low Prevalence Diseases 2022

›American Journal of Emergency Medicine

›Emergency medicine perspective on esophageal perforation

›Wei CJ et al. CT and fluoroscopic esophagography 2020

›AJR American Journal of Roentgenology

›CT sensitivity 92-100%, NPV 100%

Evidence & Review

Evidence & Review