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An 83-year-old woman was brought to the emergency department (ED) by the Emergency Medical Services (EMS) due to referred anaphylactic shock. While eating, she started choking and her neck and lips swelled. Upon arrival at the ED she was confused, tachycardic and hypotensive (heart rate 130 bpm, blood pressure 86/40 mm Hg); the hypotension was slightly improved by colloid and dopamine infusion. A crackling feel to the touch of the neck, suggesting subcutaneous emphysema, developed in the following minutes, and rapidly increased. During fibrescope intubation a meat bolus in the upper oesophagus was revealed. An emergency neck and chest CT scan confirmed subcutaneous emphysema (figures 1 and 2, asterisks), a foreign body in the upper oesophagus (figure 1, black arrow), massive subcutaneous air in the neck (figure 1, white arrow) and pneumomediastinum (figure 2, white arrow) compressing mediastinal veins (figure 2, black arrow) and blocking venous blood flow to the heart, generating an obstructive shock.1 In the operating room, surgeons successfully removed a meat roll fixed by a wooden toothpick from the oesophagus. The toothpick had punctured the oesophagus and generated a valve mechanism inflating air with positive pressure in the mediastinum; the tension pneumomediastinum promptly reverted after surgery and, after few days in the intensive care unit, the patient was discharged.
Contributors FS, ER and FT equally contributed to the planning, conduct and reporting of the case report. FS is responsible for the overall content as guarantor.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; internally peer reviewed.