Extensive Subcutaneous Emphysema Research Articles

UNUSUAL PRESENTATION OF PNEUMOMEDIASTINUM AND SUBCUTANEOUS EMPHYSEMA MIMICKING ANGIOEDEMA

SESSION TITLE: Case Report Semifinalists 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a relatively safe technique associated with a very low complication rate for the sampling of mediastinal and hilar lymph nodes. Here we report a rare case of pneumomediastinum and subcutaneous emphysema following EBUS-TBNA. CASE PRESENTATION: 72 years old female, past smoker with remote history of right breast cancer s/p lumpectomy, radiation and chemotherapy (20 years ago), referred for evaluation of a 2.2 cm left hilar mass. She underwent elective EBUS under deep sedation after uneventful placement of a laryngeal mask airway, with transbronchial needle aspiration in the subcarinal (7) and left hilar stations (10L). There were no immediate complication. Two hours post procedure she developed rapidly progressive facial and neck swelling without any stridor. She was initially thought to have angioedema, and was intubated for airway compromise after she received IV Methylprednisolone 125 mg, IV epinephrine 10 mcg and 30 mcg subcutaneous epinephrine without improvement. No laryngeal edema was seen during intubation. Chest X ray subsequently showed extensive pneumomediastinum and subcutaneous emphysema. The decision was made to extubate patient since there was a risk of developing pneumothorax because of positive pressure. Patient was found to have air leak prior to extubation and was extubated to nasal cannula. Patient was discharged the next day to follow up as an outpatient. DISCUSSION: EBUS-TBNA is a safe procedure and complications are minimal. There are only a few case reports of pneumomediastinum associated with airway trauma from EBUS-TBNA so far. Subcutaneous emphysema may be observed in association with pneumomediastinum once pressure gradients allow air to spread via the fascial planes to the surrounding soft tissues [1]. Subcutaneous emphysema can mimic angioedema, an often a relatively benign disorder. Clinical presentations may include dramatic swelling of the neck associated with chest pain, wheezing, dyspnea, and dysphagia. Sparing of lips and presence of crepitus can be an important clue to differentiate it from angioedema [2]. Management of pneumomediastinum and sub cutaneous emphysema depends upon the clinical severity. Most patients respond well to the conservative management,however surgery may be required in rare cases. Treatment should be aimed at decreasing intrathoracic pressure spikes by reducing coughing and straining. CONCLUSIONS: Although EBUS-TBNA is considered a safe procedure with rare complications, it is necessary to remember that serious complications such as pneumomediastinum can occur. Our patient’s unusual presentation led to initial misdiagnosis. Although rare, clinicians must remain mindful of the complication to avoid delay in treatment. Reference #1: Ortiz, R., Hayes, M., Arias, S., Lee, H., Feller-Kopman, D. and Yarmus, L. (2014). Pneumomediastinum and Pneumopericardium after Endobronchial Ultrasound–Guided Transbronchial Needle Aspiration. Annals of the American Thoracic Society, 11(4), pp.680-681. Reference #2: Dhawan, A., Singal, A., Bisherwal, K., & Pandhi, D. (2016). Subcutaneous emphysema mimicking angioedema. Indian Dermatology Online Journal, 7(1), 55. https://doi.org/10.4103/2229-5178.174304 DISCLOSURES: No relevant relationships by Kulothungan Gunasekaran, source=Web Response No relevant relationships by Gini Priyadharshini Jeyashanmugaraja, source=Web Response No relevant relationships by Min Qiao, source=Web Response No relevant relationships by Daniel Rudolph, source=Web Response No relevant relationships by Christopher Winterbottom, source=Web Response

PNEUMOMEDIASTINUM FROM SPIROMETRY AND RESPIRATORY FUNCTION TESTING AFTER MEDIAN STERNOTOMY AND THYMECTOMY: A CASE REPORT

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Pneumomediastinum is the presence of air within the mediastinum. Causes include parenchymal lung disease, violent coughing, and vomiting and chest surgery. Spirometry testing is a rare cause of pneumomediastinum. We report a case of pneumomediastinum due to pulmonary function testing and spirometry in a man who underwent thymic surgery. CASE PRESENTATION: A 52 year old man underwent median sternotomy and thymectomy for a 9x7cm thymoma discovered after diagnosis of myasthenia gravis. Chest drains were removed by post-operative day (POD) 2. The patient received chest physiotherapy, incentive spirometry and twice daily negative inspiratory force (NIF) and forced vital capacity (FVC) measurements as recommended by Neurology. On POD 5, he reported a change in voice quality and facial swelling. Subcutaneous crepitus was palpable over the right chest, neck and cheek. A computed tomographic (CT) study of the thorax showed extensive pneumomediastinum, pneumopericardium and subcutaneous emphysema extending to the right temporal fossa. Upon review of our patient’s NIF and FVC measurements, he was found to have an increased FVC daily with an FVC of 3L prior to the onset of his symptoms. The patient was commenced on bed rest with limited ambulation around his cubicle. Spirometry and the NIF and FVC measurements were stopped and he was commenced on empirical antibiotics. He reported improvement of his facial swelling within 24 hours and daily chest radiographs demonstrated improvement in the subcutaneous emphysema. The patient remained clinically well and was discharged on POD 8 with a course of oral antibiotics. DISCUSSION: The pathophysiology of pneumomediastinum suggests that following alveolar rupture, air enters the perivascular adventitia and dissects proximally into the mediastinum. Pneumomediastinum following chest surgery should prompt the clinician to rule out pneumothorax and mediastinitis and monitor for obstructive symptoms, air embolism and subcutaneous emphysema. When significant pathology has been excluded, treatment is directed towards symptom relief. In our patient, we postulate that the rapid increase in lung volume and pressure changes in the alveolus from the inspiratory function tests and incentive spirometry, coupled with breaches of the pleura and pericardium during surgery, had caused air to dissect into the subcutaneous plane, mediastinum and pericardial space. CONCLUSIONS: Incentive spirometry helps prevent postoperative pulmonary complications and aids recovery of pulmonary function in patients undergoing thoracic surgery. Our case highlights the need to be aware of potential complications of spirometry and pulmonary function testing in motivated patients, especially following thoracic surgery. Reference #1: Manco, JC, Terra-Filho, J, and Silva, GA. Pneumomediastinum, pneumothorax and subcutaneous emphysema following the measurement of maximal expiratory pressure in a normal subject. Chest. 1990; 98: 1530–1532 DISCLOSURES: No relevant relationships by Atasha Asmat, source=Web Response No relevant relationships by Shaun Chan, source=Web Response No relevant relationships by Jacqueline Chua, source=Web Response

SUDDEN ONSET FACIAL SWELLING IN A PATIENT WITH IDIOPATHIC PULMONARY FIBROSIS MIMICKING ANGIOEDEMA

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Subcutaneous emphysema (SE) is a well known complication that can be seen following thoracic surgical procedures. Angioedema is a localized swelling of subcutaneous tissue usually the face, tongue and upper airway. We present a case of SE of the face initially mistaken for angioedema. CASE PRESENTATION: A 69 year old male, recently diagnosed with Idiopathic Pulmonary Fibrosis (IPF) after a robotic-assisted thoracoscopic biopsy of the left upper & lower lobes, a month prior presented to his primary care physician with complaints of low grade fever & non productive cough. He was treated for acute bronchitis with a course of azithromycin & prednisone which he reported to have completed. He presented to the emergency department, 4 days after completion of the antibiotic course with 1 day history of increasing shortness of breath & 2 days of worsening facial & neck swelling (Figure 1). He also had severe coughing fits days prior. Notably he denied any tongue swelling, stridor or throat tightness. There was initial concern for allergic reaction causing angioedema & was treated with IV methylprednisolone & an H1/H2 blocker in the ED. Exam showed stable vitals, diffuse crackles as well as palpable crepitus in the chest, neck and face. A subsequent chest X-ray showed extensive SE, pneumomediastinum & a small right sided pneumothorax (PTX) (Figure 2). Patient was admitted to ICU for close monitoring. A computed tomography scan of the chest demonstrated extensive SE involving chest, neck, and face; It also showed deep connective tissue space involvement (Figure 3). The small right PTX was stable. Patient was seen by thoracic Surgery who recommended conservative management. Patient remained stable & was discharged home after 3 days. DISCUSSION: Given that his small PTX was on the contralateral side of his biopsy it is unlikely that this was a post surgical complication 1 month post operatively. It is more likely that this patient had small subpleural bleb that ruptured causing air to enter the subcutaneous tissues. SE is most commonly due to an air leak from lung parenchyma, but other causes have been described such as after esophageal resections or airway trauma. This is usually a self-limited & benign complication, in rare instances stridor & respiratory collapse have also been described. This patient’s recent antibiotic exposure raised concern for angioedema. Angioedema has different causes including allergic reactions & can cause rapid swelling of the face & upper airway structures. Angioedema may be life threatening if airway structures are involved or if it is in association with anaphylaxis. CONCLUSIONS: Rapid facial swelling has a limited differential, which includes angioedema and SE, careful history and physical is vital to make the diagnosis. . Reference #1: Abu-Omar Y, Catarino P. Progressive subcutaneous emphysema and respiratory arrest, J R Soc Med 2002,95: 90-91 Reference #2: Kim YS, Risk factors for extensive subcutaneous emphysema after closed-tube throacostomy for spontaneous pneumothorax Reference #3: Loverde D, Files DC, Krishnaswamy G. Angioedema. Crit Care med 2017 Apr;45(4):725-735 DISCLOSURES: No relevant relationships by Kristoffer Neu, source=Web Response No relevant relationships by Muhammad Salick, source=Web Response No relevant relationships by Ali Wazir, source=Web Response No relevant relationships by Robert Wilcott, source=Web Response

Spontaneous Pneumopericardium in a U.S. Marine: Do not Lose Heart.

We report an unusual case of extensive subcutaneous emphysema, pneumomediastinum, and pneumopericardium identified in an otherwise healthy U.S. Marine who was enrolled in the Marine Corps School of Infantry. His training regimen included prolonged periods of yelling and elevation changes during sustained hiking through hilly terrain. The patient presented to the Fast Track with normal vital signs but complained of dyspnea, cough, and subjective fevers. Although he lacked a history of trauma, he was found to have pneumopericardium, pneumomediastinum, and subcutaneous emphysema without pneumothorax. He was admitted to the general surgery service for observation and was ultimately released back to his unit after 24hours. To our knowledge, pneumopericardium has never been attributed to persistent yelling in the setting of a lower respiratory tract infection and should be considered in the differential of atraumatic chest symptomatology in otherwise healthy military service members.

Management of extensive subcutaneous emphysema using vacuum-assisted closure therapy

Subcutaneous emphysema, pneumomediastinum, and pneumopericardium, are a spectrum of disorders, rare in children (1). literature incidence was 0.0025% for spontaneous pneumomediastinum among emergency department visits (2). We present a 7 years old came with a complaining of shortness of breath (SOB) with neck swelling and he was mildly distressed. CT scan showed right pneumothorax, pneumomediastinum, pneumopericardium and extensive subcutaneous emphysema. In the operating room (OR), intercostal chest tubes were inserted bilaterally and bilateral transverse sub-clavicular incisions connected to a vacuum assistant wound closure device (VAC). VAC was found to be effective technique in the management of a massive subcutaneous emphysema. • Subcutaneous emphysema, pneumomediastinum, and pneumopericardium, are a spectrum of disorders, rare in children. • They are group of disorders delineated by abnormal existence of air in the correspondent anatomical location. • Presentation can be widely different, ranging from a mild respiratory symptoms to a life threatening acute respiratory event. • CT scan has been found more sensitive and specific in the diagnosis. • VAC was found to be effective, safe and advisable technique for shortening the management period of a massive subcutaneous emphysema and was to be found safe in pediatric.

Challenging Diagnosis of Severe Bilateral Cervicofacial Subcutaneous Emphysema following Root Perforation in a Maxillary Lateral Incisor: A Case Report.

Cervicofacial subcutaneous emphysema (CFSE) is a rare complication. CFSE may happen following some dental procedures including root canal therapy and is caused by unintentional entry of air into potential spaces of head and neck. In the current report, a case of extensive bilateral subcutaneous emphysema -following the root perforation of a maxillary anterior tooth- is presented. A 26-year-old woman was referred for further consultation concerning her right maxillary lateral incisor; for which a poor prognosis was considered following an endodontic treatment. There was a history of sudden facial swelling during root canal therapy. With the exacerbation of the problem and experiencing other symptoms, she was hospitalised. CT scan showed bilateral extension and penetration of air into submandibular, peri-orbital and parapharyngeal spaces. Clinical and radiographic evaluations of the maxillary lateral incisor revealed mid-root perforation on its buccal side, which was sealed by MTA. Eventually, the tooth was successfully restored.

Massive subcutaneous emphysema after traumatic pneumothorax.

A simple case/asymptomatic pneumothorax not deemed to necessitate drainage can quickly change, and patient safety can be compromised. Chest tube insertion with increased suction is considered a safe and efficient strategy in patients with extensive subcutaneous emphysema following traumatic pneumothorax.

Complete Tracheal Transection Following Blunt Trauma: A Case Report and Review of Literature

Traumatic tracheobronchial injury is rare, but can be life-threatening. It is often associated with other fatal injuries. Early diagnosis and prompt treatment are crucial to produce the best outcome. We are reporting a 40-year-old gentleman, a lorry driver who had a head on collision with a car. He was brought to the casualty with an intact airway. ATLS was initiated and lead by trauma team. Subsequently in casualty, his conscious level dropped and he became distressed, hence a standard orotracheal intubation was performed. Following intubation, he developed massive subcutaneous emphysema to the neck and upper chest. Computed tomography (CT) showed tracheal injury at C7- T2 level, extensive subcutaneous emphysema, pneumomediastinum with malposition of the endotracheal tube. Emergency neck exploration was performed in operating theatre, and revealed a complete transection of trachea at the level of 2nd and 3rd tracheal ring. No other vital structures were injured. A tracheostomy was created, and the patient was managed in ICU for one day. Four days following the first surgery, he was transferred to a more specialized center for tracheal refashioning and anastomosis. The patient was discharged home later without a tracheostomy. In tracheobronchial injury, high level of suspicion based on clinical judgement is vital for prompt diagnosis, with adjunct of radiological investigation. Surgical intervention to establish a patent airway in operating theatre is undoubtedly crucial in a complete tracheal transection to prevent secondary insult from tissue hypoxia. In managing such injury, advance preparation should include setups for bronchoscopy and thoracotomy. Patient survival depends on preparation and prompt surgical intervention. A tailored surgical approach is often necessary for definitive repair.

Concurrent retroperitoneal, mediastinal, cervical and subcutaneous emphysema secondary to iatrogenic sigmoid colon perforation

A 76-year-old woman patient without a remarkable medical history underwent colonoscopy because of diarrhoea and black stool for 1 month. Colonoscopy was aborted at 23 cm from the anal verge...

Managing Progressive Subcutaneous Emphysema in Patient on Invasive Positive Pressure Ventilation

Subcutaneous emphysema (SE) results from air leak from lung parenchyma into the least resistance subcutaneous tissues. Mostly a self limiting condition but extensive subcutaneous emphysema (ESE) may lead to anxiety, disfigurement, discomfort, respiratory embarrassment, upper airway obstruction and systemic air embolism and requires active management. We report successful management of progressive SE in a patient on invasive positive pressure mechanical ventilation using a newer approach and also discuss the role of surgical tracheostomy as a rescue measure.
 Bangladesh Med J. 2017 May; 46 (2): 66-67

Risk Factors of Extensive Subcutaneous Emphysema after Closed-Tube Thoracostomy for Spontaneous Pneumothorax

Risk Factors of Extensive Subcutaneous Emphysema after Closed-Tube Thoracostomy for Spontaneous Pneumothorax

Extensive Subcutaneous Emphysema after Laparoscopic Cholecystectomy, two Cases Reports

Extensive Subcutaneous Emphysema after Laparoscopic Cholecystectomy, two Cases Reports

The Case Files

Figure: Pneumomediastinum and subcutaneous emphysema at the base of the neck.FigureFigureAn 18-year-old healthy man presented to the ED with a sore throat. He said the pain had started a day earlier when he took three capsules of Molly and drank heavily at a music festival. The patient reported pain while swallowing, shortness of breath, and pain in his left rib cage after playing basketball a few days earlier. The patient had no jaw or neck pain, coughing, fever, chills, nausea, vomiting, and diarrhea. He had a blood pressure of 126/76 mm Hg, temperature of 98.2°F (orally), heart rate of 70 bpm, respirations of 18 bpm, and oxygen saturation of 100% on room air. The physical exam demonstrated an alert, awake, and oriented patient with evidence of tenderness in the left rib cage. There were no signs of abdominal tenderness, respiratory distress, or asymmetrical breath sounds. The lungs were clear bilaterally, and the heart sounds were normal. The chest x-ray showed some linear air density streaks in the mediastinum. A CT with and without contrast revealed an extensive pneumomediastinum and considerable subcutaneous emphysema at the base of the neck, posterior right thoracic region, and left axillary area. The results were reviewed with the patient, but he signed out against medical advice after being told of the seriousness of his condition. The patient was advised to return if the condition worsened. Methylenedioxymethamphetamine (MDMA) is an amphetamine derivative commonly abused by young adults. It is also known as Ecstasy, Molly, Adam, Doves, and Skittles. MDMA promotes social closeness, increases energy, alters sensations, and induces euphoria. The drug has a strong affinity for serotonin receptors and transporters, causing a release of serotonin and a decrease in its uptake at the synaptic clefts. Onset is 30-60 minutes with a duration of action of eight to 24 hours. As a sympathomimetic, the initial onset can produce an elevated heart rate and anxiety. The National Institute of Drug Abuse reported that 11.6 percent of adults 18-25 have taken MDMA at least once. (Sept. 26, 2017; http://bit.ly/2RByI2H.)Figure: CT of pneumomediastinum and subcutaneous emphysema.Spontaneous pneumomediastinum can be seen in patients with underlying lung disease due to the rupture of a bleb. Other conditions that can contribute to pneumomediastinum include choking, the Valsalva maneuver, cough, extreme exertion, barotrauma, and helium gas inhalation. Fifty-five percent of spontaneous pneumomediastinum cases present with chest pain, and 40 percent present with dyspnea. Neck pain, odynophagia, and dysphagia are present in less than 20 percent of cases. Sore throat is an uncommon initial presentation that must also be taken into consideration.Figure: CT of pneumomediastinum.Ordinarily, the mean pressure in the mediastinum is more negative than the pressure in the pulmonary alveoli. In spontaneous pneumomediastinum, pressure differences rupture the alveoli, allowing free air to travel through the hilum. Air then spreads into the mediastinum by way of loose fascia. Rare Complications Pneumomediastinum and subcutaneous emphysema are rare complications of amphetamine use. The pathophysiology of pneumomediastinum after the use of amphetamines is unclear. Pharmacologically the link is yet to be determined between the stimulant and the leakage of air into the mediastinum. It is theorized that initially various mechanisms change the transmural pressure in the alveoli, which can cause rupture of the alveoli, leading to subcutaneous emphysema. The free air then reaches the mediastinum by dissecting along the bronchovascular layers and fascial planes. Commonly the transmural pressure is changed in cases that involve mechanical ventilation, the Valsalva maneuver, or an extreme straining that occurs during strenuous coughing or vomiting. In this case, an initial increase in alveolar pressure could have arisen from strenuous dancing and vigorous activity and compounded by the surge in activity due to prolonged use of MDMA. A 2011 case report found a previously healthy military trainee developed spontaneous pneumomediastinum after repeatedly yelling “hooah” in a squad competition event. (Mil Med 2011;176[3]:352.) The workup should begin with a chest x-ray to provide a definitive quantification of pneumomediastinum. It does not need to include a CBC, BNP, or CMP. Mild spontaneous pneumomediastinum is self-limiting. Patients can be managed conservatively with analgesia, rest, and by avoiding increased pulmonary pressure. Moderate to severe symptoms are treated with high-concentration oxygen, which will increase the nitrogen washout. A patient with underlying lung disease, however, should receive more aggressive measures to avoid absorptive atelectasis. It is important to understand the multifaceted presentation, pathophysiology, management, and treatment of MDMA-induced subcutaneous emphysema and pneumomediastinum.

Extensive Subcutaneous Emphysema after Laparoscopic Cholecystectomy, Two Cases Reports

Extensive Subcutaneous Emphysema after Laparoscopic Cholecystectomy, Two Cases Reports

Extensive emphysema after intramedullary nailing of apertrochanteric fracture : Life-threatening infection or benign complication

The development of emphysema after intramedullary nailing can represent an easily manageable complication but in the differential diagnostics it could, however, be alife-threatening infection with Clostridium perfringens. This is a report about the case of an extensive subcutaneous and retroperitoneal emphysema, which developed after intramedullary nailing of apertrochanteric femoral fracture and where such an infection was suspected.

IS IT ANGIOEDEMA OR AIR?

Introduction Angioedema can present with acute facial and upper airway swelling that may be potentially life threatening. Diagnosis is made clinically based on history and exam findings. In patients with concern of airway compromise, immediate airway protection and treatment is indicated. It is important to evaluate for mimickers of angioedema which may have similar presentations but differing treatments. Periorbital edema Photograph of patient taken on day of admission Case Description A 45-year old man presented following a motor vehicle accident. He developed periorbital edema which progressed to the face, uvula, and larynx requiring intubation. He had history of unprovoked uvular and throat swelling treated with corticosteroids. Family history was significant for lip and eyelid swelling in multiple family members. Although not known to have been prescribed ACE inhibitors, a bottle of lisinopril was discovered in the patient's belongings. Physical examination found bilateral periorbital edema and edema of the neck without erythema or warmth. Subcutaneous crepitus was not appreciated. Initial CT imaging demonstrated pneumothorax. Angioedema from antibiotic drug allergy, ACE-inhibitors and hereditary or acquired C1 inhibitor deficiency angioedema were considered. Treatment was initiated with H1 and H2 antihistamines, epinephrine, systemic corticosteroids, fresh frozen plasma, and plasma-derived C1 esterase inhibitor without improvement. C4 level was normal. Repeat CT imaging revealed the development of extensive subcutaneous emphysema of the face and eyelids. He recovered with supportive care. Discussion This patient's case highlights the importance of considering a broad differential when evaluating for suspected angioedema of the neck and face including subcutaneous emphysema, contact dermatitis, cellulitis, and superior vena cava syndrome.

Pneumoretroperitoneum, Pneumomediastinum, and Subcutaneous Emphysema Due to Retroperitoneal Penetration After Endoscopic Mucosal Resection of the Ascending Colon Where Only Right Cervical Pain Was the Initial Symptom

INTRODUCTION: Intestinal perforation is one of the most serious complications of colonoscopy. Its diagnosis and treatment may be delayed by the presence of unexpected symptoms. We present a case of pneumoretroperitoneum, pneumomediastinum, and subcutaneous emphysema that occurred due to retroperitoneal penetration by EMR at the ascending colon with the initial symptom as right cervical pain alone. CASE PRESENTATION: The patient is a 51-year-old man. Colonoscopy revealed LST of about 15 mm in diameter at the lower ascending colon (Figure. 1). Then, EMR was performed. After EMR, the patient complained of mild right cervical pain. We thought that the pain would be due to changes in posture, so we did not pay particular attention to it.2154_A Figure 1. Colonoscopic findings. Approximately 15mm lateral spreading tumor is located on the lower-ascending colon.Four hours later, the patient developed a fever of 37?, complained about exacerbation of the right cervical pain, and started to complain of right-sided abdominal pain. There was tenderness on the right flank to the back, and on the right neck, with no definite signs of peritoneal irritation. Clear crepitus was palpated around the neck, the right side of the chest, and the right back. A computed tomography (CT) scan revealed massive pneumoretroperitoneum around the dorsal side of the ascending colon to the back side of the lumen, pneumomediastinum, and extensive subcutaneous emphysema around neck, right side of the chest, and right flank to the back of the abdomen, consistent with palpation (Figure 2). We decided on conservative treatment because his condition was stable and there were no signs of peritonitis. Under conservative treatment, his symptoms gradually improved without the need for surgical intervention.2154_B Figure 2. Computed tomography (CT) findings. (a) Subcutaneous emphysema of the neck. (b) Pneumomediastinum. (c) Right pneumoretroperitoneum and subcutaneous emphysema at right renal level. (d) Pneumoretroperitoneum around the dorsal side of the ascending colon just with clips after EMR back side of the lumen.DISCUSSION: The majority of the signs of colorectal perforation are abdominal symptoms, such as acute peritonitis. However, in this case, the patient complained of right cervical pain after EMR was performed. It seemed to penetrate the retroperitoneum and was the only initial symptom. Initially we had no doubts about perforation. It seems that the penetrating air reached to the neck in a very short time. Perforation by colonoscopy usually causes symptoms of peritonitis due to intraperitoneal perforation, but in the case of retroperitoneal penetration, emphysema develops outside the peritoneum, causing various symptoms located in parts other than the abdomen, such as the neck. Since cervical pain alone can manifest as a sign of perforation, we should try to find the perforation earlier based on a few symptoms.

ABDOMINAL WALL NECROTIZING FASCIITIS: A RARE COMPLICATION OF PERCUTANEOUS GASTROSTOMY

SESSION TITLE: Critical Care 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Percutaneous gastrostomy is a commonly performed procedure for providing enteral nutrition in patients with head and neck cancers, stroke and bulbar palsy. A number of non-infectious and infectious complications of percutaneous gastrostomy have been reported previously. Abdominal wall necrotizing fasciitis is a rare but life-threatening complication of percutaneous gastrostomy [1]. Here, we report the case of an elderly lady, who developed gastrostomy-site necrotizing fasciitis and expired consequently. CASE PRESENTATION: An 81-year-old lady with past history of end-stage renal disease and anoxic brain injury (requiring tracheostomy and percutaneous gastrostomy placement) was transferred from a long-term facility with a 3-day history of fever. On physical examination, she was noted to have discoloration of skin around the gastrostomy site (Figure 1). Her laboratory investigations revealed leukocytosis (white cell count of 44,700/mm3) with a neutrophilic predominance (92%). Computed tomography of the abdomen (Figure 2 and Figure 3) demonstrated extensive subcutaneous emphysema (arrows in Figure 3) throughout the anterior abdominal wall along with infiltration of the subcutaneous fat (arrowheads in Figure 3). A diagnosis of necrotizing fasciitis of the gastrostomy site was made and broad-spectrum antibiotic therapy (vancomycin, meropenem and clindamycin) was started. Subsequently, two sets of blood culture grew carbapenem-resistant Klebsiella pneumoniae for which colistin (polymyxin E) and meropenem were instituted. Surgical debridement of the abdominal wall was discussed with the patient’s family. However, surgical intervention was not pursued in line with her goals of care and she expired subsequently. DISCUSSION: Abdominal wall necrotizing fasciitis is a rare complication of percutaneous gastrostomy with an estimated incidence of 1 in 129 gastrostomy procedures [2]. Dislodgement of the gastrostomy tube is implicated in most cases (as in this case) and allows infection by gas-producing organisms. Buried bumper syndrome (i.e. erosion of internal bumper of feeding tube into gastric wall due to pressure necrosis) is another factor that may be implicated in some cases [2]. Patient-related risk factors include old age, obesity, diabetes mellitus, immunocompromised status and chronically bedridden patients. Treatment consists of aggressive surgical debridement and broad-spectrum antibiotics. Mortality rates are reported to be as high as 30% despite surgical interventions [3]. CONCLUSIONS: Necrotizing fasciitis is a rare but potentially fatal complication of percutaneous gastrostomy. Prompt recognition and aggressive management with surgical debridement and broad-spectrum antibiotics may afford a favorable outcome for some patients [3]. As gastrostomy tubes are widely used in critically ill patients, intensivists and radiologists must be aware of this rare but life-threatening complication. Reference #1: Lockett MA, Templeton ML, Byrne TK, Norcross ED. Percutaneous endoscopic gastrostomy complications in a tertiary-care center. Am Surg. 2002;68:117-120. Reference #2: Grant DG, Bradley PT, Pothier DD, et al. Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis. Clin Otolaryngol. 2009;34:103-112. Reference #3: Artul S, Nseir W, Assaf V, Abboud N. Abdominal wall necrotising fasciitis due to dislodged percutaneous endoscopic gastrostomy tube. BMJ Case Rep. 2014;2014:bcr2013201346. DISCLOSURES: No relevant relationships by Hafiza Noor Ul Ain Baloch, source=Web Response No relevant relationships by Michael Silverberg, source=Web Response

Extensive surgical subcutaneous emphysema secondary to the use of a high‐speed dental handpiece: a case report and discussion

AbstractSurgical subcutaneous emphysema is known to be a potential complication of the use of high‐speed air‐driven dental drills (air turbines) and compressed air syringes. Often, however, we assume that it is just a theoretical risk to be taught to undergraduates that never actually happens in practice. Here, we present a case of extensive surgical subcutaneous emphysema secondary to tongue trauma from a high‐speed drill, extending far from the site of air entry.

Concurrent Spontaneous Pneumomediastinum and Pneumorrhachis

BackgroundSpontaneous pneumomediastinum with concurrent pneumorrhachis (air in the spinal canal) and subcutaneous emphysema can be an alarming presentation, both clinically and radiographically. These clinical entities often require only conservative measures after ruling out any worrisome underlying causes. Management often involves appropriate imaging, hospital admission, and sub-specialty consultation as needed to help determine any potential causes for the presentation that may require anything more than a period of medical observation. Case ReportA 20-year-old man presented to the Emergency Department (ED) with acute onset of chest pain. Physical examination was significant for subcutaneous emphysema across the anterior chest wall. Radiographs of the neck revealed extensive soft tissue emphysema extending into the upper mediastinum. Computed tomography (CT) of the neck with contrast revealed a small amount of air within the central canal of the spinal cord, in addition to extensive pneumomediastinum and subcutaneous emphysema. The patient remained stable and was discharged home on hospital day 2, after significant threats for morbidity or mortality were ruled out. Why Should an Emergency Physician Be Aware of This?Spontaneous pneumomediastinum, pneumorrhachis, and subcutaneous emphysema are rare clinical entities, but each requires thorough investigation in the ED to rule out any underlying life-threatening cause. A conservative treatment approach is appropriate for most patients without evidence of cardiorespiratory compromise or neurologic deficits accruing due to these problems.