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PubMedDate not supplied

Radiographic and CT findings of blunt chest trauma: aortic injuries and looking beyond them.

Increasingly, helical CT is being used to screen trauma patients for aortic injury. Most aortic injuries visible at CT occur at or near the level of the ligamentum arteriosus; these injuries manifest as mediastinal hematoma, aortic contour deformity, intimal flaps, intraluminal debris, pseudoaneurysm, and pseudocoarctation. In the process of searching for aortic injury, however, the radiologist should not overlook other serious and more common thoracic injuries. Tracheobronchial tears appear at CT and radiography with persistent pneumothorax, subcutaneous emphysema, "fallen lung" sign, and malposition of endotracheal tube. The ruptured diaphragm, which tears more often on the left, appears asymmetric, irregular, or discontinuous, with herniation of bowel or viscera into the chest. In esophageal rupture, CT and radiography demonstrate left pneumothorax, pneumomediastinum, subcutaneous emphysema, and pleural effusion and atelectasis on the left. CT is better than trauma radiography for depicting fractures of the thoracic vertebral bodies and ribs, as well as for revealing pulmonary contusions and lacerations. CT is also useful for demonstrating unsuspected injuries caused by seat belts. Observation of these injuries should prompt a search for other serious internal organ injuries.

Aorta, Thoracic↗
PubMed2003

Equine immune-mediated hemolytic anemia associated with Clostridium perfringens infection.

BACKGROUND: Previous studies have suggested an association between equine immune-mediated hemolytic anemia and clostridial infections or neck abscesses. OBJECTIVE: The purpose of this report was to describe and characterize the hematologic abnormalities in a horse with Clostridium-associated immune-mediated hemolytic anemia. We also retrospectively evaluated hematologic abnormalities in 8 horses with clostridial myositis or subcutaneous emphysema. METHODS: A 7-year-old Foreign Warm-Blood gelding was evaluated for anemia and a cervical abscess. CBCs and reticulocyte counts were obtained using an Advia 120 analyzer and evaluation of Wright's-stained smears. All cases of equine Clostridium spp.myositis or subcutaneous emphysema over a 7-year period were identified in a retrospective search of the University of Minnesota Veterinary Teaching Hospital database. Clinical, hematologic, and microbiological findings were recorded. RESULTS: Clostridium perfringens genotype A was isolated from the neck wound of the gelding. The CBC was characterized by severe regenerative anemia, intravascular hemolysis, and RBC agglutination. A direct Coombs' test was positive. Moderate numbers of spheroechinocytes were observed. The total automated reticulocyte count was 4.5% (56,700/microliter), with most reticulocytes having low absorbance (mature reticulocytes). The anemia responded to penicillin and steroidal and nonsteroidal immunosuppressive drugs. Of 8 horses with myositis, all of which involved the cervical region, 5 were anemic, 1 had a positive direct Coombs' test, and 2 had increased numbers of type III echinocytes and spheroechinocytes. CONCLUSIONS: The presence of type III echinocytes or spheroechinocytes may be helpful in diagnosing immune-mediated hemolytic anemia associated with clostridial infections in horses. Automated reticulocyte counts may detect very low levels of reticulocytosis in hemolytic anemia in horses.

Abscess↗
PubMed1994

[anorexia nervosa; an association with certain types of soft tissue emphysema].

A 17-year-old female with anorexia nervosa developed pneumomediastinum, subcutaneous emphysema, retroperitoneal emphysema, interstitial pulmonary emphysema and epidural emphysema (epidural emphysema; air between the dura mater and the vertebral arch). She had no history of bronchial asthma. The mechanism was presumed to be weakness of the alveolar wall due to malnutrition, leading to rupture of alveoli, followed by air entering the interstitium and dissecting along perivascular sheaths (interstitial pulmonary emphysema) into the mediastinum. A further increase in mediastinal pressure may bring about opening of the fascial planes along great vessels and allow air to penetrate into subcutaneous tissues and the spinal canal. These types of emphysema have been reported in bronchial asthma cases and in those on positive pressure breathing. To our knowledge, there are no previous reports of anorexia nervosa associated with these phenomena.

Adolescent↗
PubMed2004

Acute airway distress from endotracheal intubation injury in the pediatric aerodigestive tract.

OBJECTIVES: Two unusual cases of pediatric aerodigestive tract trauma postintubation with subsequent complications are described. Pediatric retropharyngeal dissection from trauma has not been reported previously. METHODS: We conducted a retrospective chart review in a pediatric tertiary care center. RESULTS: A 6-year-old girl underwent attempted nasotracheal intubation. She sustained retropharyngeal dissection, receiving positive pressure ventilation before this injury was noted. She developed subcutaneous emphysema. The child was managed conservatively and did well. An 8-year-old boy sustained a 4-cm laceration of his posterior trachea, developing pneumomediastinum after intubation. On transfer to our institution, he underwent direct laryngobronchoscopy and was reintubated with the tip of the endotracheal tube distal to the laceration. Postoperatively, the child accidentally pulled his tube and coughed, resulting in severe subcutaneous emphysema with increased pneumomediastinum. An emergent tracheotomy was performed. The patient subsequently did well. CONCLUSION: A higher index of suspicion with more careful surveillance may prevent further morbidity.

Child↗
PubMed2002

Diagnosis and treatment of tension pneumothorax under anesthesia: a case report.

An 80-year old woman with a history of tracheal stenosis, tracheostomy, and 3 months of increasing respiratory distress underwent tracheal dilatation under general anesthesia with jet ventilation. Tracheal dilatation was successfully performed via suspension laryngoscopy and jet ventilation. During emergence the patient developed decreased oxygen saturation, hypotension, and respiratory distress, requiring intubation and ventilatory support. During tracheostomy, anterior chest subcutaneous emphysema led to a diagnosis of tension pneumothorax. Chest tube placement facilitated tracheostomy and improved ventilatory and circulatory parameters. This article discusses the diagnosis and treatment of a tension pneumothorax under general anesthesia. Jet ventilation, spontaneous rupture of blebs or bullae, surgical trauma, or barotrauma are the 4 most likely explanations for a tension pneumothorax in this patient. Jet ventilation can cause pneumothorax, pneumomediastinum, or subcutaneous emphysema. Chronic obstructive pulmonary disease may cause blebs or bullae, which might rupture when exposed to positive pressure ventilation. Tissue trauma during dilatation or tracheostomy may cause a pneumothorax when positive pressure ventilation is employed. Barotrauma from high peak inspiratory pressure, rigid bronchoscopy, dilatation procedure, or jet ventilation may cause a pneumothorax. Prompt diagnosis and treatment will markedly decrease associated morbidity and mortality.

Aged↗
PubMed2002

Percutaneous dilatational tracheostomy is as safe as open tracheostomy.

Although percutaneous dilatational tracheostomy (PDT) has been advocated as an alternative to open tracheostomy (OT) its relative safety has been questioned repeatedly. This study prospectively compared the safety and complications of PDT and OT. Ninety-four patients underwent PDT and 252 patients underwent OT at this institution from December 1998 through April 2000 with the choice of procedure left to the operator. OT was performed in the operating room whereas PDT was performed in intensive care units (ICUs). PDT was performed by surgeons and medical intensivists under a strict institutional policy and procedure governing patient selection and conduct of the procedure. Complications were defined as bleeding, loss of airway, hypotension, hypoxia, tracheostomy tube malposition, subcutaneous emphysema, infection, and conversion of PDT to OT. All patients survived the operation. PDT and OT had similar complication rates: 2.1 per cent for PDT versus 2.8 per cent for OT (P = not significant). Postoperative bleeding, which was the most frequent complication, occurred in one PDT patient and four OT patients. One PDT patient required conversion to OT as a result of extensive tracheal fibrosis. Subcutaneous emphysema, soft-tissue infection, and a malpositioned tracheostomy tube were the remaining complications in the OT patients. We conclude that the complication rates of PDT and OT are comparable. The choice of PDT or OT should be dictated by the surgeon's training and experience, the patient's condition, neck anatomy, and stability for transfer to the operating room.

Aged↗
PubMed2003

A case of dermatomyositis complicated with pneumomediastinum successfully treated with cyclosporin A.

We describe a rare case of a 46-year-old Japanese man with dermatomyositis (DM) and interstitial lung disease who developed spontaneous pneumomediastinum and subcutaneous emphysema. Relatively mild myositis, mild elevation of CK values and the absence of anti-Jo-1 antibody were observed and the case was similar to amyopathic DM. Treatment of this patient with oral prednisolone and cyclosporin A (CsA) was effective for the myositis and interstitial lung disease. The administration of CsA enabled rapid tapering of the dose of prednisolone without aggravating the disease. Pneumomediastinum and subcutaneous emphysema disappeared 5 months later without recurrence. The serum levels of KL-6 were monitored every 2 weeks to help determine whether this may have contributed to the recurrence of interstitial pneumonitis. This is a rare case of pneumomediastinum in a patient with DM.

Administration, Oral↗
PubMed1996

Pneumomediastinum in childhood asthma.

The objective of this study was to examine the presentation and clinical course of patients with asthma and pneumomediastinum (PNMD). A retrospective chart review was performed from a computer-generated list of all patients discharged from an urban children's hospital between 1981 and 1991 with the diagnoses of asthma and PNMD. Thirty cases and 30 controls with asthma, matched for age and sex, were identified. The incidence of PNMD and asthma was 0.3%. Mean age was 11.8 years with a male:female ratio of 1.15:1. Chest pain was reported in 27% of patients and 13% of controls (P = 0.17). There was no difference in presenting respiratory rate, heart rate, or systolic blood pressure between cases and controls, nor was there a difference in respiratory distress by modified Wood-Downes scale. Fifty percent of patients had room air oxygen saturation measured at presentation. There was a significant difference in mean oxygen saturation between those with PNMD and those without (90.4 vs 94.1 %; P = 0.03). Subcutaneous emphysema was detected in 73% of cases versus none in controls (P < 0.001; positive predictive value (PPV) = 100%). Sixty-seven percent of patients with PNMD had repeat radiographs during hospitalization. Of these x-rays, 85% showed no change in, improvement, or complete resolution of the PNMD. Three patients (15%) developed a small increase in the PNMD. No patient developed pneumothorax, pneumopericardium, or deterioration in cardiovascular status. PNMD is a rare complication of asthma. Subcutaneous emphysema was the most useful predictor of PNMD in asthma. Chest pain and diminished oxygen saturation should heighten suspicion. Further complications of PNMD were exceedingly rare, and all patients recovered uneventfully, suggesting that attention to excellent treatment for the acute exacerbation may be sufficient in most instances of PNMD.

Adolescent↗
PubMedDate not supplied

[Spontaneous pneumomediastinum as a complication of asthma in adultsand adolescents].

The objective of this study was to examine the percent of spontaneous pneumomediastinums (SPM) as a complication of asthma in children and adolescent, and to examine the symptoms and clinical signs which predict SPM. A retrospective analysis was performed of patients discharged from Srebrnjak Hospital between 1988 and 1991 with the diagnoses of asthma and SPM. Ten cases (8 males and 2 females) aged 4-19 years were compared with 50 hospitalized patients. SPM was found in 4.96% of patients. Mean age of patients with SPM and asthma was 11.2 and of control patients 11.45 years. Chest pain was reported in 5/10 patients with SPM and asthma and in 0/50 of controls (p < 0.01). Subcutaneous emphysema was detected in 9/10 patients with SPM and asthma and in 0/50 of controls (p < 0.01). There was no difference in respiratory distress, partial oxygen pressure and oxygen saturation, heart rate and respiratory rate between cases and controls (p > 0.05). Systolic pressure was higher in children with SPM, but the values were within normal limits. During hospitalization in 3 patients with SPM partial left pneumothorax developed, in 1 partial bilateral pneumothorax and in 2 pneumopericardium. Subcutaneous emphysema is a significant specific clinical sign, and chest pain is a predominant symptom in the diagnosis of SPM. The patients with asthma and SPM must be treated in hospital because of potential further complication.

Adolescent↗
PubMed2003

Tracheal perforation secondary to suture irritation in a dog following a ventral slot procedure.

An eight-year-old springer spaniel was presented with acute-onset subcutaneous emphysema of five days' duration. The dog had undergone ventral slot decompression of the C5-C6 intervertebral disc space eight weeks before presentation. Cervical tracheoscopy demonstrated perforation of the dorsal tracheal membrane of the distal cervical trachea. Perforation of the dorsal tracheal membrane secondary to suture knot irritation was confirmed by exploratory surgery. Repair of the perforation was performed by plication of the dorsal tracheal membrane. The dog was re-presented nine days after the initial surgery with acute recurrence of subcutaneous emphysema. Air leakage at the plicated dorsal tracheal membrane was observed at exploratory surgery, and a bipedicle sternothyroideus muscle flap was used to support the plicated membrane. Recovery was uneventful and 10 months postoperatively there had been no recurrence of clinical signs.

Animals↗
PubMed2000

Tracheal rupture caused by blunt chest trauma: radiological and clinical features.

The aim of this study was to assess radiomorphologic and clinical features of tracheal rupture due to blunt chest trauma. From 1992 until 1998 the radiomorphologic and clinical key findings of all consecutive tracheal ruptures were retrospectively analyzed. The study included ten patients (7 men and 3 women; mean age 35 years); all had pneumothoraces which were persistent despite suction drainage. Seven patients developed a pneumomediastinum as well as a subcutaneous emphysema on conventional chest X-rays. In five patients, one major hint leading to the diagnosis was a cervical emphysema, discovered on the lateral cervical spine view. Contrast-media-enhanced thoracic CT was obtained in all ten cases and showed additional injuries (atelectasis n = 5; lung contusion n = 4; lung laceration n = 2; hematothorax n = 2 and hematomediastinum n = 4). The definite diagnosis of tracheal rupture was made by bronchoscopy, which was obtained in all patients. Tracheal rupture due to blunt chest trauma occurs rarely. Key findings were all provided by conventional chest X-ray. Tracheal rupture is suspected in front of a pneumothorax, a pneumomediastinum, or a subcutaneous emphysema on lateral cervical spine and chest films. Routine thoracic CT could also demonstrate these findings but could not confirm the definite diagnosis of an tracheal rupture except in one case; in the other 9 cases this was done by bronchoscopy. Thus, bronchoscopy should be mandatory in all suspicious cases of tracheal rupture and remains the gold standard.

Adult↗
PubMedDate not supplied

[Withdrawal of chest tubes without water seal vs. negative continuous suction after closed cardiovascular surgery procedures in children].

BACKGROUND: We undertook this study to compare the frequency and type of complications, as well as the length of hospital stay, in children who underwent closed cardiovascular surgery with chest tube drainage during the postsurgical period with children in whom the drainage was withdrawn with continuous suction, once thoracotomy was completed. METHODS: A retrospective, descriptive and analytic study was performed at the IMSS Hospital de Pediatria, located at the XXI Century National Medical Center in Mexico City. Eighty eight children who underwent closed cardiovascular surgery (Group I) without chest tubes and 42 with chest tubes (Group II) were studied. RESULTS: In Group I the frequency of complications was 27.3% and in group II 59.5%. Complications were as follows: subcutaneous emphysema was seen in 13.6% (n=12) of group I and in 45.2% (n=19) of group II (p=0.0001); pneumothorax in 13.6% (n=12) vs. 28.6% (n=12), p=0.04; and chylothorax in 2.3% (n=2) vs. 2.4% (n=1), p=1.0, respectively. The median time of hospital stay in group I was 3 days and in group II was 6 days (p=0.0001). CONCLUSIONS: In children, in some closed cardiovascular surgeries, withdrawal of chest tube drainage with negative suction when thoracotomy is completed may decrease the frequency of pneumothorax, subcutaneous emphysema and length of hospital stay, in comparison with patients in whom chest tube drainage is left during the postoperative period.

Cardiovascular Diseases↗
PubMed2001

[A case of dermatomyositis complicated with pneumomediastinum that was successfully treated with cyclosporin A].

We reported the case of a 39-year-old man with dermatomyositis (DM) complicated with subcutaneous emphysema and pneumomediastinum during steroid therapy. The patient had complained of muscle weakness, dyspnea and skin eruption on his anterior chest wall 6 months prior to admission. He was diagnosed as having DM on the basis of an elevation in myogenic enzymes, myogenic changes in electromyography, a skin biopsy and a muscle biopsy. Chest roentgenogram revealed interstitial pneumonia (IP) in the lower lobes of the lungs. The administration of prednisolone (60 mg/day) was initiated, which resulted in improvement of DM. Fifteen days after the initiation of the steroid therapy, the patient developed subcutaneous emphysema and pneumomediastinum. Additional administration of cyclosporin A (CsA) enabled us to rapidly taper the dose of prednisolone without aggravating the diseases. Several reports have shown that vasculitis might be involved in the pathogenesis of pneumomediastinum in DM patients. Infection and tissue fragility due to steroid therapy worsen the outcome of those patients. CsA therapy may improve the outcome through the anti-vasculitic- and steroid sparing-effects.

Adult↗
PubMed2005

Surgical emphysema following tonsillectomy.

Complications of tonsillectomy have been well documented. However subcutaneous emphysema of the neck following tonsillectomy has rarely been described. We report a case of this complication in a young man who forcefully performed Valsalva's maneuver following a tonsillectomy.

Adult↗
PubMed2005

Management of tracheobrochial injuries: a 10-year experience at Ratchaburi hospital.

BACKGROUND AND OBJECTIVE: Tracheobronchial injuries are rare but life threatening. Their successful diagnosis and treatment require a high level of suspicion and early surgical repair The authors review their experience in managing these injuries over the past 10 years. MATERIAL AND METHOD: Patients who were admitted to the Thoracic Surgical Unit, Ratchaburi Hospital and treated for tracheobronchial injuries from 1993 to 2004 were included in the present study. Hospital records were reviewed on mechanism of injury, clinical presentation, diagnosis, management and outcome. RESULTS: The present series comprised of 11 tracheobronchial injury patients. Causal mechanism of injury was 4 blunt and 7 penetrating injuries. 4 of them with blunt injury, there were 3 right main bronchial disruptions, 1 minor cervical laceration. Presenting signs included dyspnea in 4 and subcutaneous emphysema in 3. 1 of them had massive air leak. Radiographic finding were pneumomediastinum in 3. Pneumothorax in 2, Atelectasis of right lung in 1. All of the right bronchial disruptions had primary repair with reanastomosis in 2 and resection of stenotic bronchus with reanastomosis in 1; this patient developed empyema thoracis with Acinetobacter iwoffii as a result of delayed diagnosis (40 day). One patient with minor cervical laceration underwent conservative treatment. All patients with blunt injuries were discharged with a normal patency of airway. 7 patients with penerating injuries, there were 4 cervical, 1 cervical associated with esophageal injury, 1 combined cervical-thoracic type of injuries and 1 Thoracic injury. Presenting signs included dyspnea in 7 and subcutaneous emphysema in 6. The radiographic finding were pneumomediastinum in 5 pneumothorax in 4, one patient underwent tracheal reanastomosis. The rest of six patients underwent immediate primary repairs. One patient with cervical knife stap wound died 4 hours postoperatively of hemoptysis, progressive hypoxia and aneuria, 6 of them were recovered with a normal patency of airway CONCLUSION: The authors concluded that, result of treatment for tracheobronchial injury should depend upon the mechanism of injury, early recognition, early diagnosis and appropriate surgical intervention. Delay in diagnosis is the single most important factor-influencing outcome. Common complications in the early phase were hypoxia, organ failure while in the late phase were sepsis, tracheal or bronchial stenosis, mediastinitis and chronic bronchopleural fistula, etc.

Adolescent↗
PubMed2004

[Blunt chest trauma with total rupture of the right main stem bronchus--a case report].

Tracheo-bronchial lesions in blunt chest trauma are rare--the incidence is about 1%--but potentially life-threatening events. Indirect signs such as pneumothorax, pneumomediastinum, subcutaneous emphysema or an insufficient expansion of the lungs after drainage of a pneumothorax are ominous. The fastest and most reliable method to assess the definite diagnosis of tracheo-bronchial lesion is fibre-optic tracheobronchoscopy. Early surgical treatment is mandatory to prevent major pulmonary resection. This case shows that computer tomography might fail to provide the right diagnosis. Independent lung ventilation is an option to protect the bronchial anastomosis during the early postoperative period. Reported here is the case of a young man who sustained a total traumatic rupture of the right main stem bronchus after being thrown from the passenger seat through the windshield of a motor vehicle. When the emergency doctor arrived on the scene, he found the patient with dyspnoea and massive thoracic subcutaneous emphysema. Reduced breath sounds on the left and no breath sounds on the right side led to an immediate placement of two chest tubes and controlled mechanical ventilation. After primary care in a district hospital, the patient was transferred to our university hospital for further treatment of his head injury. On admission, the patient was making breath sounds on both sides and a CT scan showed no clear sign of a tracheo-bronchial lesion. After neurosurgical intervention, the diagnosis of a rupture of the right main stem bronchus was made with delay by fibre-optic bronchoscopy. The patient was intubated with a left-sided double lumen endotracheal tube followed by surgical end-to-end anastomosis of the lesion. The initial postoperative ventilator support consisted of BIPAP-mode ventilation of the left lung, while the right lung was kept open with positive airway pressure. Forty-eight hours later, synchronised independent lung ventilation with two ventilators was established to protect the surgical result. The ventilation was switched to conventional mode a further 48 hours later. Extubation and the remaining ICU stay were uneventful.

Accidents, Traffic↗
PubMed2005

The management of chest tubes in patients with a pneumothorax and an air leak after pulmonary resection.

BACKGROUND: Placing chest tubes to water seal is superior for patients with an air leak, but when a patient has a pneumothorax and an air leak the best chest tube setting is unknown. METHODS: This is a retrospective analysis of a prospective database on a consecutive series of patients who had a pneumothorax and air leak on the same day. Patients underwent elective pulmonary resection by one surgeon and had their chest tubes placed to water seal on postoperative day 1. Daily chest radiographs were obtained, and the size of the pneumothorax and air leak were measured. Tubes were left on seal unless there was a symptomatic enlarging pneumothorax or subcutaneous emphysema (defined as failing water seal). The primary objective was to evaluate the efficacy of water seal. We also wanted to identify risk factors that predicted failure of water seal. RESULTS: There were 838 patients > or = 21 years old who underwent elective pulmonary resection, and 86 patients (10%) had an air leak and a concomitant pneumothorax on the same day. Fourteen patients (16%) failed water seal. Multivariate analysis showed that a large air leak (greater than or equal to expiratory 3 in our classification system; odds ratio [OR], 16.5; p < 0.001) and a pneumothorax > 8 cm in size (OR, 4.9; p < 0.005) were predictors of failing water seal. CONCLUSIONS: Keeping chest tubes on water seal is safe for most patients with an air leak and a pneumothorax. However, if the leak or pneumothorax is large, then subcutaneous emphysema or an expanding symptomatic pneumothorax is more likely. A prospective randomized trial is needed to compare water seal to suction in these patients.

Chest Tubes↗