History

Mediastinitis manifests within a spectrum that ranges from the subacute patient to the fulminant critically ill patient who requires immediate intervention in order to prevent death.

The typical postoperative patient presents with fever, high pulse, and report symptoms suggestive of a sternal wound infection (eg, sternal instability). Approximately two thirds of patients present within 14 days following surgery. Although a delay of months is occasionally observed, signs or symptoms typically develop within 1 month of the operation. Patients may report sternal pain that has increased since surgery, drainage from the wound site, an audible click due to sternal nonunion, and progressive redness over a variable period.

Physical Examination

Vital signs generally may show tachycardia and fever. In more advanced cases of sepsis, hypotension may be present, and the patient may require large volumes of crystalloid or vasopressor medication for support.

The Hamman sign is a crunching sound heard with a stethoscope over the precordium during systole. Its presence should alert the clinician to possible mediastinitis, though its absence does not change the probability of disease.

Direct signs of sternal infection may be among the initial presenting signs or may be delayed until after the diagnosis is already considered. Sternal pain, instability, or click; local cellulitis; and drainage can all be observed.

Distinguishing between a superficial wound infection and a deeper chest infection associated with mediastinitis can be challenging. Systemic signs of sepsis strongly suggest mediastinal involvement. Local wound exploration should be utilized as a mechanism to distinguish a superficial wound infection from a deep sternal wound infection.

Workup

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