EMS Eponymous Condition - Mackler’s Triad

Mackler’s Triad is a clinical diagnostic tool associated with spontaneous esophageal rupture, also known as Boerhaave syndrome. It includes three key symptoms:

• Vomiting: Usually forceful and occurs before the rupture.
• Lower Chest Pain: Sudden onset after vomiting.
• Subcutaneous Emphysema: Air trapped under the skin, often detected around the neck or chest, creating a crackling sensation upon palpation (due to air leaking from the esophagus).

EMS providers should be aware that Boerhaave Syndrome is a life-threatening condition that requires immediate medical intervention. 

Early recognition of the symptoms in Mackler’s Triad is critical, as delayed diagnosis and treatment significantly increase the risk of morbidity and mortality.

Key Points for EMS Providers:

High suspicion after forceful vomiting: If a patient presents with intense chest pain after vomiting, suspect an esophageal rupture.

Subcutaneous emphysema: Feel for air under the skin, especially in the neck and chest areas.

Transport to a higher level of care: Esophageal ruptures require surgical intervention and antibiotics to prevent fatal infections such as mediastinitis (infection in the chest cavity).

Stabilization: Manage the airway, ensure the patient is NPO (nothing by mouth), administer IV fluids if necessary, and provide pain control.

Who Was Mackler?

Dr. Sydney S. Mackler was an American physician and surgeon who first described the triad in 1952. He made significant contributions to understanding and diagnosing Boerhaave syndrome. 

The triad is named after him due to his work linking these three symptoms to spontaneous esophageal rupture, helping to guide clinicians in making this often elusive diagnosis.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell