Hamman’s Syndrome and DKA
Certainly 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:
- 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
- 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.
- 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.)