A 45-year-old woman is admitted to the medical intensive care unit with persistent retrosternal chest pain, increasing dyspnea, and signs of systemic inflammatory response syndrome. She initially presented to the emergency department 18 hours prior with severe epigastric discomfort radiating to her back and profuse vomiting following a heavy meal and alcohol consumption. Her medical history includes chronic alcohol use disorder and a previous admission for gastritis. On current examination, she appears distressed, has marked subcutaneous crepitus palpable in her neck and supraclavicular fossae, and diminished breath sounds over the left lung base. Her temperature is 38.9° C (102.0° F), blood pressure is 85/50 mm Hg, pulse is 125/min, and respirations are 30/min with shallow breaths. Initial chest X-ray showed a small left pleural effusion and mediastinal air. A subsequent CT scan of the chest confirmed a contained esophageal rupture with extravasation of contrast into the mediastinum and a large left-sided empyema. Pleural fluid analysis obtained during thoracentesis showed a purulent exudate with a pH of 6.5 and an amylase content of 3100 IU/L. Given these findings, what is the most appropriate immediate therapeutic intervention, and what characteristic finding on a subsequent contrast esophagography would definitively confirm the primary diagnosis?

A 55-year-old female presents to the emergency department with acute onset of severe retrosternal chest pain that began shortly after an episode of forceful vomiting following a large meal. She describes the pain as sharp and radiating to her left shoulder. She denies any prior history of similar pain or cardiac issues. On examination, she appears acutely distressed. Her vital signs are T 38.2 C (100.8 F), BP 100/60 mmHg, HR 110/min, RR 24/min, SpO2 94% on room air. Auscultation of the chest reveals diminished breath sounds and dullness to percussion over the left lower lung field. A faint Hamman's sign is suspected on cardiac auscultation. Initial chest X-ray shows a left-sided pleural effusion with evidence of mediastinal widening. Cardiac biomarkers are negative. A thoracentesis is performed, and laboratory studies show: Considering the patient's presentation and initial findings, which definitive diagnostic study should be pursued, and what immediate therapeutic intervention is indicated?

A 22-year-old man who initially presented to his primary care physician with a 3-week history of recurrent episodes of severe retrosternal chest pain, often triggered by self-induced vomiting after large meals. He mentioned a long-standing struggle with body image and episodic bulimic behaviors. Today, he presents to the emergency department after a particularly forceful emetic episode, reporting excruciating, tearing retrosternal pain radiating to his back. The pain is severely aggravated by swallowing, deep inspiration, and even slight movement. He is extremely anxious, diaphoretic, and in acute distress. His vital signs are: Temperature 99.8°F (37.7°C), Pulse 140/min (thready), Blood Pressure 85/50 mmHg, Respiratory Rate 32/min, O2 Saturation 92% on room air. On examination, there is marked tenderness to palpation over the lower sternum. Auscultation of the chest reveals distant heart sounds and crepitus noted over the supraclavicular fossae and anterior chest wall (Hamman's sign). Abdominal examination is unremarkable, but he exhibits guarding with any palpation. Given his clinical presentation and rapid deterioration, which of the following is the most probable diagnosis and the most critical immediate intervention?

A 65-year-old woman with a history of chronic acid reflux is brought to the emergency department after experiencing sudden, severe retrosternal chest pain and shortness of breath following an episode of intractable vomiting at home. Her family reports she had been feeling unwell with persistent nausea for the past 24 hours. On arrival, her vital signs are: temperature 39.2°C (102.6°F), blood pressure 88/45 mm Hg, pulse rate 120/min, and respiratory rate 28/min with shallow breaths. Oxygen saturation is 88% on a non-rebreather mask. Physical examination reveals muffled heart sounds, crepitus noted on palpation over the left supraclavicular area, and absent breath sounds with dullness to percussion over the left hemithorax. Her abdomen is soft with mild epigastric tenderness. A stat bedside chest X-ray shows a large left pleural effusion, pneumomediastinum, and subcutaneous emphysema. Given these findings, what is the most appropriate immediate management strategy, and what definitive surgical intervention is typically required for this condition?