It turns out he had not just ingested K2 but had been in jail for five days and remained altered.
Our patient had air in the neck because of a pneumomediastinum. The initial read on the CT of the head revealed the air and also a calcified object in the hypopharynxBecause of the possibility of a foreign body in a psychiatric patient, he was scoped at the bedside and no foreign body was seen. A CT of the chest was done showing air around the heart. Thoracic surgery was consulted and suggested a swallow study to rule out esophageal perforation.
Esophageal perforation carries a high mortality rate ranging from 10-30% . Treatment depends on the location and size of the perforation. Cervical perforations are usually small and can be treated conservatively, while larger perforations in the thoracic esophagus can be treated with stents. Perforation of the abdominal portion of the esophagus usually requires surgery as does a perforation in any patient with a large perforation or sepsis. . In very ill patients, esophageal exclusion surgery can be carried out until the patient’s condition stabilizes.
Pneumomediastinum without esophageal perforation is commonwith Valsalva especially in drug users. It was first described in 1819 by Rene Laennec. Individuals with pneumomediastinum often present with sore throat or pain with swallowing.
calcified stylohyoid ligament
Our patient’s course
The patient by this time was waking up and doing abdominal crunches in the bed; one after another. He also would bring his shoulders forward and fists together in front of him and grunt. When asked what he was doing, he stated he was the “Hulk” and was turning green. He jumped out of bed and fought with several security guards requiring leather restraints and chemical sedation. Radiology felt a swallow could not be done safely at this point and he was admitted to CCU , the only ICU bed available. The overread on the initial CT showed a calcified stylohyoid ligament and not a foreign body. He eventually got the swallow which was negative and was transferred to Psych where he remains pending discharge back to jailon a 21 day involuntary hold.
It’s not easy being green.
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Lawrence DR, Moxon RE, FountainSW, Ohri SK. Iatrogenic oesophageal perforations: a clinical review. 1998. Ann R Coll SurgEngl. 80;115-118.
Fajardo LL. Association of spontaneous pneumomediastinum with substance abuse. Western Journal of Medicine 1990. 152(3); 301-304.
Laennec RTH. De l’aucultation mediate ou Traite du Diagnostic des Maladies des Poumon et du Coeur. 1st ed Paris. Brosson & Chaude, 1819.