Choosing Wisely After Blunt Trauma: When Pneumomediastinum Does Not Require Escalation.

BackgroundMost patients with pneumomediastinum from blunt injury have a self-limited condition and additional testing is no longer recommended given the low incidence in underlying aerodigestive injury. This study characterizes practice patterns in evaluating patients with diagnosed pneumomediastinum.MethodsData from a level 1 trauma center were analyzed from 2013 to 2022 for blunt trauma patients with pneumomediastinum diagnosed by imaging of the chest. Outcomes analyzed included mechanism of injury, diagnostic studies, procedures, and presence of an aerodigestive injury.Results351 patients were included; 71% were male; 35% were transfers. The most common mechanisms of injury were MVC (54%), fall (11%), and motorcycle/ATV accident (11%). 227 patients had pneumomediastinum and pneumothorax on CT (65%). Of the 124 with isolated pneumomediastinum on CT scan (35%), 96 had reliable mental status (GCS ≥13) and all were asymptomatic of an aerodigestive injury. 9 (9.4%) underwent endoscopy or esophagram with no injuries identified. No patients were diagnosed with an esophageal injury. Seven patients (2%) were diagnosed with tracheal injury; all presented with physical exam findings (subcutaneous emphysema, respiratory failure, and/or dysphonia), none with isolated pneumomediastinum. 12 patients (9.6%) were transferred with isolated pneumomediastinum. Of the transfer population, twenty did not meet criteria for trauma activation upon arrival (16%) and five were discharged from the emergency department (4%).ConclusionAerodigestive injuries amongst patients with radiographically diagnosed pneumomediastinum are rare. However, many asymptomatic patients are assessed with additional diagnostic tests and are potentially overtriaged with transfers to higher levels of care.