Mediastinitis in Emergency Medicine Treatment & Management

Updated: Feb 10, 2015
  • Author: James R Gardner, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Treatment

Prehospital Care

Mediastinitis may result in airway compromise. Protection of the airway is vital. Since patients may present in septic shock, adequate volume resuscitation is essential.

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Emergency Department Care

Ensure an adequate airway. Do not allow a patient who is potentially unstable to be placed into the CT scanner without ensuring that the airway is adequately protected. Intubation may be difficult because of soft tissue swelling. Fiberoptic assistance may be required, and an emergent cricothyrotomy or tracheostomy may become necessary. In addition to the usual complications of intubation, it may be further complicated by trauma to the retropharyngeal wall, laryngospasm, or aspiration of purulent material.

Antibiotic therapy should be initiated without delay.

Fluid resuscitation and management of sepsis are essential.

The key component of ED management is expeditious diagnosis. Mediastinitis may present a confusing clinical picture and may be mistaken for entities such as pneumonia, acute coronary syndrome, pharyngitis, or isolated pharyngeal abscess, among others. A high index of suspicion is required, particularly in patients with findings of a concomitant cervicopharyngeal infection or with a history of thoracic, esophageal, or tracheal instrumentation or malignancy. Prompt diagnosis and surgical treatment is associated with improved survival.

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Consultations

Immediately make arrangements for surgical consultation. Extensive and aggressive debridement of necrotic tissues with exploration of all mediastinal fascial spaces may be required. Controversy exists about whether the cervical approach or the transthoracic approach is best. Some physicians support a combination of the two approaches. In some case series, the combination approach has been associated with a lower mortality rate. Depending on the resources available, consultations may include otorhinolaryngology, cardiothoracic surgery, and general surgery.

The necessity for extensive drainage may mandate the transfer of some patients to a tertiary referral center.

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