Hamman’s Syndrome and DKA

Hamman's SyndromeCertainly there are many issues to consider while diagnosing and managing diabetic ketoacidosis (DKA), like the possibility of cerebral edema. Often, these ill patients complain of significant nausea and abdominal / chest pain as well. Before we just attribute those symptoms completely to the pathologic process of DKA, let’s consider the potential complication of pneumomediastinum by being vigilant for Hamman’s Syndrome:


Hamman’s Syndrome: Basics

  • Hamman’s Syndrome is SPONTANEOUS pneumomediastinum and emphysema. [Pain, 2017]
  • High intrathoracic pressures leads to: [Grapatsas, 2017; Pain, 2017]
    • Overdistension and rupture of the alveoli
    • Air tracking along the bronchovascular bundles.
    • Air tracking to the subcutaneous tissues of the:
      • Neck
      • Pericardium
      • Retroperitoneum
      • Posterior mediastinum
      • Intervertebral foramen and into the epidural space
    • Possible pneumothorax.
  • Symptoms: [Grapatsas, 2017; Pain, 2017]
    • Chest pain
    • Neck pain
    • Upper abdominal pain
    • Shortness of breath
  • Signs: [Pain, 2017]
    • Subcutaneous emphysema
    • Hamman’s sign = precordial crunching or popping sound during systole
  • Diagnosis:
    • Chest X-ray is all that is really needed.
    • Chest CT
      • More sensitive for spontaneous pneumomediastinum, but does not specifically change management.
      • May be needed to rule out Boerhaave’s Syndrome (esophageal rupture).
        • Very rare complication of forceful vomiting.
        • High mortality rate though.
        • Often associated with subconjunctival hemorrhages, facial petechiae.
        • Requires clinical judgement to determine whether risk of Boerhaave’s syndrome in a particular patient warrants risk of CT radiation.
  • Management:
    • Spontaneous pneumomediastinum will typically resolve … umm… spontaneously.
    • Therapies should be geared toward underlying associated condition (i.e., treat the DKA).
    • Prognosis is excellent. [Pain, 2017]


Hamman’s Syndrome and DKA

  • Patients presenting with DKA are at risk of developing spontaneous pneumothoraces for a few separate reasons: [Pain, 2017; Kamei, 2016]
    • Increased intrathoracic pressures from Kussmaul’s respirations [Hirayama, 2016]
    • Vomiting, related to acidosis, ketosis, and gastroparesis, increases intrathoracic pressure.
    • Fibrotic changes of the lungs seen in patients with poorly controlled diabetes increases risk for alveolar rupture.
  • Hamman’s syndrome may be mistaken for:
    • Symptoms of uncomplicated DKA
    • Kussmaul’s respirations


Moral of the Morsel

  • Stay vigilant! Yes, patients with DKA have a great reason to feel terribly, but they also have increased risk for complications!
  • Chest pain or shortness of breath should catch your attention! A CXR is likely all that is needed though, particularly in the hemodynamically stable and afebrile patient.
  • Save the CT for Boerhaave’s Syndrome! This will require your clinical experience to sort out from Hamman’s Syndrome. (It’s a good thing you are skilled.)



Grapatsas K1, Tsilogianni Z1,2, Leivaditis V3,4, Kotoulas S1, Kotoulas C1, Koletsis E4, Iliadis IS1, Dahm M2,3, Trakada G5, Veletza L5, Kallianos A5, Huang H6, Kosmidis C7, Karanikas M8, Thomaidis V9, Porpodis K10, Zarogoulidis P11. Hamman’s syndrome (spontaneous pneumomediastinum presenting as subcutaneous emphysema): A rare case of the emergency department and review of the literature. Respir Med Case Rep. 2017 Dec 11;23:63-65. PMID: 29276676. [PubMed] [Read by QxMD]

Pain AR1, Pomroy J1, Benjamin A1. Hamman’s syndrome in diabetic ketoacidosis. Endocrinol Diabetes Metab Case Rep. 2017 Nov 30;2017. PMID: 29218226. [PubMed] [Read by QxMD]

Kamei S1, Kaneto H2, Tanabe A2, Shigemoto R2, Irie S2, Hirata Y2, Takai M2, Kohara K2, Shimoda M2, Mune T2, Kaku K2. Hamman’s syndrome triggered by the onset of type 1 diabetes mellitus accompanied by diabetic ketoacidosis. Acta Diabetol. 2016 Dec;53(6):1067-1068. PMID: 27294657. [PubMed] [Read by QxMD]
Bickley J1. Hamman syndrome. Br J Hosp Med (Lond). 2016 Mar;77(3):191. PMID: 26961454. [PubMed] [Read by QxMD]
Hirayama I1, Hiruma T2, Ueda Y2, Doi K2, Nakajima S2. Hamman syndrome: pneumomediastinum combined with hyperosmolar hyperglycemic state. Am J Emerg Med. 2016 Oct;34(10):2058. PMID: 27055605. [PubMed] [Read by QxMD]
Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

Articles: 583


  1. saw one in a 19 year-old last week in san francisco. sustained from paroxysms of coughing from influenza.

    tx = pain meds, reassurance.

    this happens in pregnant ladies all the time whilst pushing in labor. if for some reason a cxr is obtained immediately postpartum, it’s a [relatively] common incidental finding.

    i’ve been enjoying the morsels since 2012 now! keep it up.

    stephen gamboa

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