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Massive Subcutaneous Emphysema

Free Open Access Medication Discussion

regarding recent Blogpost from May 23rd, 2017.

See case below.

 

http://www.aschoolofairway.com/single-post/2017/06/28/Tracheostomy-Complications-Blood-on-the-Hands

 

Origins:

Subcutaneous Emphysema can be from pressurized air via deep diving or playing a trumpet after recent root canal or tooth extraction. 

Coughing violently and leading to Esophageal Rupture or rupture of lung bleb hence Pneumothorax.

Rigid instrumentation of the Esophagus.

Ruptured Trachea during difficult intubation.

OverBagging an Apneic patient via facemask, endotracheal tube or tracheostomy especially in a patient with diseased lung. Scar tissue from Sarcoidosis or Severe COPD or extensive Tuberculosis.

 

Positive pressure Ventilation can cause almost insignificant small subcutaneous emphysema become Massive Subcutaneous Emphysema.

 

Air can track down mediastinum and even around the heart to cause Pneumomediastinum, Pneumopericardium, respectively.

 

SubQ Air can cause extensive acute stretching of skin and lead to skin necrosis at the Breast, Scrotum or Labia.

 

Can even lead to such swelling of the eyelids, leading to Frog-Face and patient not being able to see from inability to open the patient's eyelids.

 

Once you see externally, get good at looking at it internally on cxr and ct scan.

In this case ct imaging was done of the soft tissue neck, chest, abd.

Pay attention to the video below.

.......

 

Treatment:

Take a good history to figure out where the possible airway leaks are likely.

Find the cause of air leak.

 

Treat any pain induced from the pressurized skin. Minimize cough with antitussives. Supplemental oxygen to help reabsorb the emphysema as when one uses O2 for simple small pneumothoraces.

 

Use endoscopy or an Esophagram to screen for esophageal tear if hx highly suggestive.

 

Place a large catheter like 14 or 16 guage into the subcutaneous skin, and leave distal tip of catheter open to allow active drainage of air. You can cut skin to creat "blow holes" to help release the localized trapped air.

 

If the airway is not protected and the Massive Emphysema is progressive, the patient may tire out especially from pneumothorax. Can lead to tracheal compression. The patient may need intubation. This would also make things worse hence Please urgent tx of airleak cause is emergent.

 

Chest tube if the SubQ emphysema was caused the extensive Pneumothorax especially when the patient is on the ventilator.  If not improvement, larger chest tube, or 2nd additional chest tube to be placed. Patient likely needs CT surgery for likely Bronchotracheal fistula.

 

References:

https://en.wikipedia.org/wiki/Subcutaneous_emphysema

https://www.wikem.org/w/index.php?title=Pneumomediastinum&redirect=no

 

 

 

 

 

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