Tim
If the air trapping / barotrauma phenomenon were in fact recreational drug
related, it would be interesting to know exactly what drugs, if any were
consumed.
A brief search of the literature reveals case reports describing
pneumomediastinum as a complication of general aneasthesia, bromine
(industrial gas exposure), chlorine (household cleaning agent), petrol fumes,
nitrous oxide, cocaine (snorted or freebased), crack - cocaine, and of course
ecstacy. A common theme is inhaled gas under pressure, however external
thoracic trauma has not been described as an association and therefore cannot
be used to predict who will develop problems.
I wonder how many of the ecstacy / barotrauma cases were in fact due to amyl
nitrite (liquid gold/rush/poppers) and not ecstacy per se. I suspect
'poppers' are in fact the commonest drug to accompany ecstacy use (purely
anectodal of course !) and requires the inspiratory manoeuvre Jon describes
to have maximal effect. Perhaps therefore the drug inhaled is less important
and the duration and frequency of breath holding under pressure more
important and a common theme with all these cases. More importantly is
antecedent chest trauma a predictor of a worse outcome in drug related
mediastinal emphysema ? nothing in the literature, but some postulations;
Is it possible your 22 year old chap had (1) suffered a pneumothorax
following the initial injury complicated by 'mild' mediastinal emphysema,
which then resolved (did he attend an A&E and have a CXR following the
initial injury ?), subsequently performed the valsalva to maximise drug
effect, and preferentially exacerbated the mediastinal emphysema ? or (2)
chest injury no mediastinal complications but developed after exercise (?
weight lifting ) and exacerbated by drug related valsalva or (3) chest injury
/ exercise both a red herring and as per JAEM case reports preferentially
developed mediastinal emphysema with a valsalva manoeuvre ?
(4) is he asthmatic ? :)
Shafique
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