Severe Subcutaneous Emphysema Research Articles

Mediastinitis and septic shock complicating spontaneous esophageal rupture “Boerhaave’s syndrome”: a case report

Boerhaave’s syndrome, also known as spontaneous esophageal rupture, is a rare but life-threatening condition characterized by a tear in the esophagus. It is most commonly caused by a sudden increase in intraesophageal pressure, often due to severe vomiting or retching.Early diagnosis of Boerhaave’s syndrome is crucial for improving patient outcomes. The classic triad of symptoms includes severe chest pain, vomiting, and subcutaneous emphysema (air under the skin). However, not all patients present with this triad, and the diagnosis can be challenging, especially in patients without the typical symptoms.In this case report, we present the clinical details of a 52-year-old male patient who presented to the emergency department (ED) with severe abdominal pain and vomiting for several days. The patient had a history of chronic alcohol abuse and a recent episode of vigorous vomiting.

Conservative treatment of iatrogenic tracheal rupture (clinical case)

The objective was to demonstrate a clinical case of iatrogenic injury of the trachea, which, despite its large size (length 65, width up to 25 mm), wastreated conservatively and, thus, avoided risks for the patient associated with the need for technically complex surgical intervention.Materials and methods. A 65-year-old patient diagnosed with peripheral cancer of the lower lobe of the left lung pT2aN0M0 stage IB, who routinely underwent thoracoscopic left lower lobectomy with mediastinal lymph node dissection. During anesthesia, tracheal intubation with a double-lumen tube of the R. Shaw type was carried out with technical difficulties; during intubation, a defect in the posterior wall of the trachea in its membranous part was formed. The defect was diagnosed on the first postoperative day.Results. Despite the large size of the tracheal defect, the patient had no symptoms of respiratory failure, and there were also no signs of mediastinitis or damage to the esophagus, which almost completely covered the resulting hole in the posterior wall of the trachea. Such circumstances made it possible to avoid a potentially dangerous and complex surgical intervention, carry out conservative therapy and wait for the resulting defect to heal through granulation tissue. Enhanced antimicrobial therapy was carried out; in order to sanitize the tracheobronchial tree and monitor healing, fiber-optic bronchoscopy was performed, which made it possible to clearly demonstrate both the damage itself and the stages of its healing.Conclusions. The described case clearly demonstrates the potential for healing of even very extensive tracheal wall defects with conservative therapy. However, it is important to note that success in this clinical case was the result of a combination of circumstances – only the membranous part of the trachea was damaged; the defect was almost completely covered by the intact esophagus, which reduced the risk of developing mediastinitis and prevented the development of severe pneumomediastinum and subcutaneous emphysema. There were no signs of respiratory failure. The patient was transferred from the intensive care unit on the 13th day of the postoperative period, discharged from the hospital on the 22nd day.

A study of subcutaneous emphysema, factors contributing to its development, resolution and management with different modalities.

Subcutaneous emphysema (SE) is defined as an escape of air in subcutaneous tissue. It is one of the most common complications after intercostal chest tube drainage. SE is usually benign, requiring no specific treatment, but extensive SE can be uncomfortable and alarming for the patient. It can rarely lead to airway compromise, respiratory failure, and death. Factors leading to its development, following chest tube insertion and methods of management, have not been extensively studied and published. This was an analytical study done over 2 years on indoor patients who developed SE. These cases were managed using four different modalities and were analyzed for various factors contributing to the development, severity, and resolution of SE. The results of this study highlight that the cases of hydropneumothorax and secondary pneumothorax were significantly more predisposed to the development of severe SE (following intercostal chest tube insertion) and large air leaks as compared to others. A larger air leak develops higher grades of SE. The average time for resolution of SE was similar among the different modalities of management compared in the study.

Tracheal bifurcation repair for blunt thoracic trauma in a patient with COVID-19

BackgroundTracheobronchial injury (TBI) is a rare but potentially life-threatening trauma that requires prompt diagnosis and treatment. We present a case in which a patient with COVID-19 infection was successfully treated for a TBI through surgical repair and intensive care with extracorporeal membrane oxygenation (ECMO) support.Case presentationThis is the case of a 31-year-old man transported to a peripheral hospital following a car crash. Tracheal intubation was performed for severe hypoxia and subcutaneous emphysema. Chest computed tomography showed bilateral lung contusion, hemopneumothorax, and penetration of the endotracheal tube beyond the tracheal bifurcation. A TBI was suspected; moreover, his COVID-19 polymerase chain reaction screening test was positive. Requiring emergency surgery, the patient was transferred to a private negative pressure room in our intensive care unit. Due to persistent hypoxia and in preparation for repair, the patient was started on veno-venous ECMO. With ECMO support, tracheobronchial injury repair was performed without intraoperative ventilation. In accordance with the surgery manual for COVID-19 patients in our hospital, all medical staff who treated this patient used personal protective equipment. Partial transection of the tracheal bifurcation membranous wall was detected and repaired using 4-0 monofilament absorbable sutures. The patient was discharged on the 29th postoperative day without postoperative complications.ConclusionsECMO support for traumatic TBI in this patient with COVID-19 reduced mortality risk while preventing aerosol exposure to the virus.

OUT OF THIN AIR: A CASE OF SEVERE SUBCUTANEOUS EMPHYSEMA, PNEUMOMEDIASTINUM, AND PNEUMOTHORAX ASSOCIATED WITH COVID-19

OUT OF THIN AIR: A CASE OF SEVERE SUBCUTANEOUS EMPHYSEMA, PNEUMOMEDIASTINUM, AND PNEUMOTHORAX ASSOCIATED WITH COVID-19

Surgical Plate Fixation of Simple Rib Fractures: A Case Report

Introduction: Rib fractures can cause patient morbidity that causes long hospitalization if conservative treatment is carried out. Current international guidelines recommend a minimally incisional surgical-based treatment approach to reduce pain and provide optimal clinical benefit. Numerous studies have demonstrated that surgical fixation in conjunction with multidisciplinary integrated care pathways offers the highest therapeutic benefit for developing countries, which are typically more accountable for a higher share of unfavorable global outcomes. This case report describes the selection of appropriate decision-making in the management of multiple rib fractures. Case description: We report that a 51-year-old, still actively working young female came to our emergency department after a motorcycle accident, left chest hitting the road boundary, 2 days earlier. He presented with severe upper chest pain, chest deformity, mild dyspnea, tachycardia, subcutaneous emphysema, and hematoma. The chest radiograph shows a hypo ventilated lung field and a minor pleural effusion. A computed tomography scan showed right lateral rib fractures 3–4 posterior and 5–6 posterolateral, with areas of hyperdensity of simple bone fragments, and pulmonary contusion. Treatment consists of minimal incision with surgical fixation of the 5th and 6th posterolateral ribs which causes pain. For rib fractures 3-4, because it is stable and protected by the scapula, we only perform conservative measures. Rib fixation uses titanium reconstruction plates and cortical fixing screws. The patient's clinical condition improved rapidly postoperatively with a length of stay of 2 days after surgery. Follow-up at 6 weeks, the patient confirmed a full return to preoperative daily activities with the return to normal work activities as well as high quality of life. Conclusion: In this case report, reported that in rib fractures in a developing country, thoracic trauma can be treated through medical treatment with minimal incisions which allows rapids recovery of the patient.

Fatal non-traumatic gas gangrene caused by Clostridium perfringens type A in a Siberian Husky dog.

An 8-y-old, castrated male Siberian Husky dog was admitted to an emergency clinic with acute collapse and severe swelling of both forelimbs, ventral thorax, and axillary region. The clinical assessment, with laboratory tests and radiologic investigation, confirmed severe subcutaneous emphysema and multi-organ failure. The animal died while receiving emergency treatment. On postmortem examination, Clostridium perfringens was isolated from the subcutaneous fluid and the effusion from the thoracic and abdominal cavities. Relevant histopathology findings included subcutaneous emphysema and multi-organ perivascular and intravascular, intralesional myriad 0.5-3-µm gram-positive rod bacteria, with no associated inflammation. Whole-genome sequencing and phylogenetic analysis identified C. perfringens type A. Virulence genes detected included cpa (alpha toxin), cadA (v-toxin), colA (collagenase A), nagH (hyaluronidase), nanH, nanI, nanJ (sialidases), and pfoa (perfringolysin). These virulence genes have previously been reported to act synergistically with alpha toxin in C. perfringens-mediated gas gangrene.

Simple micro-drainage system for palliation of severe subcutaneous emphysema.

Subcutaneous emphysema (SE) occurs when air enters the tissues under the skin and passes into the soft tissues. We demonstrated a simple, minimally invasive technique for treating extensive SE, using a readily available infant nasogastric tube, in a mechanically ventilated patient.

Hyperbaric oxygen for the treatment of severe subcutaneous and mediastinal emphysema after Renuvion/J-Plasma therapy®

Subcutaneous and mediastinal emphysema are known complications of liposuction and body sculpting procedures. Treatment options are limited, and recovery is often prolonged. We discuss a case of severe subcutaneous and mediastinal emphysema after a skin-tightening procedure involving helium gas. The patient received one treatment of hyperbaric oxygen and was followed until symptom resolution. We review the known literature on hyperbaric oxygen therapy as a treatment for subcutaneous emphysema.

Pneumothorax and extensive subcutaneous emphysema in a French bulldog, following removal of a silicone tracheal stoma stent used for a temporary tracheostomy

AbstractA 3‐year‐old French bulldog was presented with a 2‐year history of a progressively worsening stertor and exercise intolerance. Clinical examination was suggestive of brachycephalic obstructive airway syndrome (BOAS). Routine laryngeal examination and computed tomography confirmed changes consistent with BOAS. A folded flap palatoplasty and vertical wedge resection alarplasty were performed. Severe dyspnea and cyanosis developed during recovery necessitating emergency intubation, and temporary tracheostomy was performed. A silicone tracheal stoma stent was placed instead of a tracheostomy tube. The silicone stoma stent was removed after 48 hours, and the patient remained hospitalised for observation for further 8 hours. Before discharge, the patient became severely distressed during IV canula removal. Rapid onset of severe subcutaneous emphysema and dyspnea necessitated emergency induction and intubation. Thoracic radiographs revealed a left‐sided pneumothorax. Following thoracostomy tube placement and drainage, a permanent tracheostomy was performed and the dog was discharged from hospital the following day.

A Patient with Severe Cervicofacial Subcutaneous Emphysema Associated with Munchausen’s Syndrome: A Case Report

Subcutaneous cervicofacial emphysema is a rare and life-threatening condition that results from various causes. In this report, we documented a case of a patient with severe subcutaneous cervicofacial emphysema a condition that falls under the umbrella of Munchausen’s syndrome and discussed the workup of this patient. Thorough diagnostic investigations seeking the etiology of the condition proved unsuccessful. When faced with cases of recurring subcutaneous cervicofacial emphysema, where the root cause remains ambiguous a diagnosis of Munchausen’s Syndrome should be considered.

A CASE OF SPONTANEOUS ESOPHAGEAL PERFORATION PRESENTING AS A RIGHT-SIDED PLEURAL EFFUSION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous esophageal perforation or Boerhaave's syndrome is characterized by rupture of the esophagus due to the rapid and spontaneous rise in intraluminal esophageal pressure. Only 14% of patients present with Meckler's triad, which includes severe vomiting, chest pain and subcutaneous emphysema. Approximately 90% of the perforations occur at the left lateral aspect of the distal esophagus, causing a left-sided pleural effusion. This case report describes an 85-year-old man who presented with Boerhaave's syndrome due to a right-sided effusion. CASE PRESENTATION: An 85-year-old male presented to the emergency department with 2 weeks of progressively worsening dyspnea, abdominal pain, nausea and vomiting. He denied a history of heavy lifting, chest trauma, alcohol or tobacco use. He was initially afebrile and hemodynamically stable. Jugular veins were not distended. Breath sounds were decreased on the right. There was no murmur and abdomen was soft nontender. ACS workup was negative. Subsequent CT scan revealed hydropneumothorax, subtle pneumomediastinum, and free intraperitoneal air. A chest tube was placed due to interval development of tachycardia & hypotension. Pleural fluid analysis yielded pH 4.23, WBC 2734, glucose 157, LDH <55, protein 2.0, amylase <26, and bilirubin <0.1. Gastrographin swallow demonstrated extravasation of contrast medium through a distal defect in the esophagus. Esophagogastroduodenoscopy showed esophageal perforation from 30 cm to 42 cm extending through the gastroesophageal junction into the cardia of the stomach with a dusky, friable, ischemic appearing distal esophageal mucosa. Rather than placing an esophageal stent as originally planned, the procedure was converted to an open esophagectomy with percutaneous endoscopic gastrostomy placement. His immediate postoperative course was largely uneventful and he was extubated post-op day 2. He was successfully discharged a few weeks later. DISCUSSION: This case is notable for a pleural fluid analysis which yielded a pH of 4.23. While pleural fluid pH is dependent on many factors and may be falsely low due to the presence of local anesthetic or heparin, exposure to air, or time delay, a pH of 4.23 in the setting of dyspnea, vomiting, and pneumomediastinum should raise concern for Boerhaave's syndrome. Another unique aspect of this case was the location of the pleural effusion. Nearly 90% of perforations are left-sided due to anatomical weakness in the left lateral aspect of the distal esophagus causing left-sided pleural effusions. This patient atypically presented with a right-sided pleural effusion. Prior literature indicates that this presentation contributes to a delay in diagnosis and subsequent increase in mortality. CONCLUSIONS: In the case presented here, vomiting, right-sided pleural effusion, and careful pleural fluid analysis aided in making the correct diagnosis and led to prompt surgical treatment. REFERENCE #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462217/ REFERENCE #2: https://www.ncbi.nlm.nih.gov/books/NBK430808/ REFERENCE #3: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153269/ DISCLOSURES: No relevant relationships by Matthew Bernens, source=Web Response No relevant relationships by Kari McCoy, source=Web Response No relevant relationships by Caroline Mears, source=Web Response No relevant relationships by David Pierce, source=Web Response

Early Post-Transplant Persistent Pneumothorax, Dehiscence or No Dehiscence?

<h3>Introduction</h3> Early pleural complications following lung transplantation (LT) are common, ranging from 22-34%. Persistent air leaks early after transplant have been associated with increased post-operative mortality. They can result from airway complications such as anastomosis dehiscence or from a peripheral communication between the lung and the pleura. <h3>Case Report</h3> A 66-year-old female with end stage hypersensitivity pneumonitis and a prior episode of right pneumothorax was admitted to the hospital with worsening hypoxemic respiratory failure. She was found to have a new right pneumothorax which improved following chest tube insertion. She was listed for LT and remained hospitalized until a donor become available. Routine bronchoscopy preformed on POD 2, prior to extubation, showed no evidence of airway ischemia. On POD 6, worsening bilateral pneumothorax with severe subcutaneous emphysema were observed on chest X ray as well as a new air leak on the right sided chest tube. CT chest demonstrated grossly intact anastomosis; however, air was seen approximating the right anastomotic site raising concern for dehiscence. An additional chest tube was inserted with no improvement. Bronchoscopy demonstrated intact anastomoses with no airway ischemia reperfusion injury, however, an open RUL accessory bronchus was noted to take off from the native trachea (Figure 1A). A 6 mm <i>Spiration e</i>ndobronchial valve was deployed at the accessory RUL bronchus (Figure 1B) with resolution of the air-leak and pneumothorax, and subsequent chest tube removal. <h3>Summary</h3> Tracheal bronchus is a known bronchial anomaly, prevalence ranging from 0.1- 2%. Persistent air leak early after transplantation raises concern for airway complications. Albeit rare, the possibility of tracheal tree abnormalities, should be considered, especially in a stable well oxygenated patient. Intrabronchial valve placement can yield good results avoiding further invasive intervention in this highly immunosuppressed population.

Severe pneumomediastinum and subcutaneous emphysema subsequent to prolonged mechanical ventilation.

Severe pneumomediastinum and subcutaneous emphysema subsequent to prolonged mechanical ventilation.

Re-expansion pulmonary edema after thoracentesis for iatrogenic pneumothorax and severe subcutaneous emphysema.

Subclavian central venous catheterization can cause severe complications, including tension pneumothorax, subcutaneous emphysema, and pneumomediastinum. Re‐expansion pulmonary edema after thoracentesis is a life‐threatening complication.

PNEUMOTHORAX AND ITS ASSOCIATION WITH SLEEP APNEA: CASE REPORT

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Spontaneous pneumothorax (SP) is the presence of air in the pleural space that could become a life-threatening illness. There are many conditions/etiologies that could develop in a spontaneous pneumothorax; such as COPD, CF, infectious diseases (like TB), AIDS, lung malignancy, connective tissue diseases, LAM, among others. There have been also an association between Obstructive Sleep Apnea (OSA) and SP. OSA is a sleep disorder characterized by recurrent collapse of the upper airways during sleep, developing episodes of no ventilation in patients (apneas). CASE PRESENTATION: We present a case of a sixty-four-year-old male with a past medical history significant for tobacco exposure, morbid obesity, obstructive sleep apnea and bullous emphysema who was admitted into the hospital due to dyspnea and left sided chest pain that occurred suddenly, with no history of trauma. Patient with imaging findings of development of a secondary spontaneous pneumothorax. Tube thoracostomy performed but in-patient management complicated with fistula formation and development of severe subcutaneous emphysema. Patient with persistent air leak for 18 days, with spontaneous resolution of pneumothorax and successful discharge. DISCUSSION: There is one previous case report that hypothesized the development of pneumothorax as an early manifestation of OSA. Our case confirms previous association, but the parenchymal effects of OSA, especially in patients like this (with extensive bullous lung disease), have not yet been evaluated. The possibility of an overlap syndrome (OSA-SP) could be emerging. The transmural gradient generated after the reduction in the intrathoracic pressure caused by the decreased in the inspiratory effort against an obstructed upper airway that develop in the hypopneas/apneas episodes; could be the responsible for barotraumas in this population. CONCLUSIONS: The apnea episodes in OSA develop alterations in the intra-thoracic pressure, that could be associated with the possible development of SP; but the pathophysiology is multifactorial and remains poorly understood. It is critical to consider that OSA could be an important predisposing factor for pneumothorax, especially in patient with extensive bullous lung disease. Reference #1: Baykal Tulek, et al. Pneumothorax as an initial manifestation of obstructive sleep apnea syndrome. Sleep Breath (2010) 14:249–251. DOI 10.1007/s11325-009-0313-z DISCLOSURES: No relevant relationships by Christian Castillo Latorre, source=Web Response No relevant relationships by Francisco Del Olmo Arroyo, source=Web Response No relevant relationships by Ilean Lamboy, source=Web Response No relevant relationships by Mariana Mercader-Pérez, source=Web Response No relevant relationships by Yomayra Otero, source=Web Response No relevant relationships by William Rodriguez-Cintron, source=Web Response

Airway compromise from traumatic pneumothorax with severe subcutaneous emphysema

Subcutaneous emphysema is commonly associated with patients who sustain blunt or penetrating trauma and rarely becomes extensive enough to compress the airway. The underlying pathophysiology involves the vast fascial and...

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.

Things to keep in mind after cardiopulmonary resuscitation: bilateral severe and widespread subcutaneous emphysema together with unilateral pneumothorax

Cardiopulmonary resuscitation (CPR) can cause severe complications such as rib and sternal fracture, pneumothorax or hemothorax. In this article, we report a case of widespread and severe bilateral subcutaneous emphysema and unilateral iatrogenic pneumothorax that does not correlate with the severity of the emphysema that occurred after active CPR.

Subcutaneous emphysema and pneumomediastinum during dental treatment

Subcutaneous emphysema is a rare complication of maxillofacial and dental surgery, and may be life-threatening because it can rapidly spread to the scalp, neck, and chest. We report a case of severe subcutaneous emphysema with pneumomediastinum during restorative dentistry in a child with difficulty in communication. The patient was hospitalized for conservative treatment and discharged after complete recovery as a result of timely diagnosis and treatment. Dentists and pediatricians should be aware of potential subcutaneous emphysema during dental treatment, with careful monitoring to ensure prompt diagnosis and treatment. Key Words: Mediastinal Emphysema; Oral Surgical Procedure; Pediatrics; Subcutaneous Emphysema; Tooth Extraction