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Local external evidence of neck trauma--bruising, subcutaneous emphysema, cuts, abrasions and so on--signs of upper airway obstruction, dysphonia and dysphagia are the hallmarks of laryngotracheal lesions. Such lesions tend to occur after motor vehicle accidents and usually require surgery. We describe a case of blunt laryngeal trauma, resulting from an unusual mechanism, which healed spontaneously.
A previously healthy 13-year-old boy developed extensive subcutaneous emphysema of the lower limb after a penetrating injury to the knee. Clostridium perfringens was isolated from the wound. Despite surgical debridement and appropriate antibiotics, the emphysema recurred, and prolonged antibiotic treatment was required. This case highlights the distinction between gas gangrene and the lesser known entity of clostridial crepitant cellulitis.
A case of laparoscopy is presented with postoperative large subcutaneous emphysema and bilateral pneumothorax. As a result of careful control, conservative treatment, and consequent oxygen administration, this life-threatening phenomena disappeared within a short time. Preventive measures for complications of diagnostic laparoscopy are discussed and established to lower the anaesthetic risk of this widely practised procedure.
Boerhaave's syndrome or spontaneous rupture of the esophagus is a rupture of the esophagus after vomiting. It is rare in children, and to date, 26 children have been reported. We present the case of a 5-year-old boy who presented with dyspnea after vomiting and subcutaneous emphysema. The diagnosis was confirmed with esophagoscopy. The patient was successfully treated with a repair of the rupture and a fundoplication. We review the literature on Boerhaave's syndrome in children.
ERCP may be associated with very serious and even fatal complications. Internal drainage with endoscopical prostheses has been used as a palliative treatment for malignant bile duct obstruction. We report a rare case of subcutaneous emphysema with a fatal outcome. The emphysema resulted from a perforation of a duodenal ulcer during ERCP due to a migrated biliary stent that had been previously endoscopically placed.
This case report describes an acute colonic diverticular perforation occurred to a multiple myeloma patient, taking corticosteroid and morphine therapy, revealed by a subcutaneous emphysema of upper chest and right abdomen as initial presentation. Sigmoid diverticulitis with perforation and generalized peritonitis is a severe complication of the diverticular disease and it is due to diverticular microperforation. This condition occurs more frequently in patients with widespread diverticolosis and usually after 50 years of age, and the frequency of related complications increases with age (and with the use of corticosteroids). Extraperitoneal air from the sigmoid-rectum perforation can escape diffusing superiorly though paravertebral retroperitoneal tissues and via the diaphragmatic iatus into the mediastinum, producing pneumomediastinum and it diffuses to yield superior thoracic emphysema. This report suggests that the diagnosis of retroperitoneal perforation is usually difficult because of the lack of signs of peritoneal irritation and the paucity of symptoms, particularly in patients treated with corticosteroids.
Our patient sustained a laceration of the membranous portion of the trachea with massive subcutaneous emphysema and pneumothorax after long-term intubation. The patient was successfully operated on within two hours. The importance of prompt diagnosis and treatment in the event of this rare complication and the different causative factors are outlined. The surgical and perioperative ventilation problems are discussed.
Tracheobronchial disruption is one of the less common injuries associated with blunt thoracic trauma. This injury can be life threatening, however, and failure to diagnose it early can lead to disastrous acute or delayed complications. Nine cases of tracheobronchial disruption in the setting of nonpenetrating thoracic trauma were seen at four Los Angeles trauma centers between 1980 and 1987. Mechanism of injury, presentation, diagnosis, and management of these patients were reviewed. Disruptions involved the trachea in 3 patients, the right bronchus in 5 patients, and the left bronchus in 2 patients. Tracheobronchial disruptions occurred in settings of high-energy impact-type injuries and were more likely to have associated injuries than they were to occur alone. Common presenting signs included subcutaneous emphysema, dyspnea, sternal tenderness, and hemoptysis. Radiographic findings were most commonly pneumothorax, pneumomediastinum, and clavicle or rib fractures. Rigid bronchoscopy and fiberoptic bronchoscopy were both highly accurate methods for diagnosis but only in the hands of trained cardiothoracic surgeons. Delay in diagnosis increased the likelihood of postoperative complications.
We report a case of tracheal rupture complicating a blunt chest trauma. As the endotracheal tube had been inadvertently inserted into the right bronchus, tracheal rupture was only suspected when increasingly severe subcutaneous emphysema occurred after mobilization of the tube. Bronchoscopy confirmed the diagnosis. After surgical repair of the lesion the outcome was uneventful. Tracheal rupture is an uncommon lesion. All physical and radiological symptoms provide useful diagnostic orientation. In the patient of our case report, inadvertent bronchial intubation made artificial ventilation possible and probably prevented lethal outcome.
A 41-year-old patient presented several episodes of desaturation during a gynaecological laparoscopy. The major complication of this procedure is the venous air embolism. Several other side-effects have been reported: heart rate disorders, subcutaneous emphysema or pneumothorax. Pleural effusions during gynaecologic laparoscopy are apparently rare and the volume of effusion must be important to induce clinical symptoms. This fact can probably explain the frequent difficulty of diagnosis. The role of the diaphragmatic lymphatic network and other physiologic aspects are discussed in this article.
Although laparoscopic cholecystectomy is gaining worldwide acceptance, it is associated with some nonsurgical complications. We report the occurrence of massive subcutaneous emphysema, bradycardia, malfunctioning oximeters, pulmonary edema, endobronchial intubation, and the patient falling from the table with change in position during this surgical procedure. Choice of anesthetics, commonly occurring anesthetic complications, and management of these problems during laparoscopic surgery are discussed.
Four cases of acute laryngeal fracture that demonstrate the history and clinical findings characteristic of blunt laryngotracheal trauma are presented. Symptoms in these patients included shortness of breath, neck pain, dysphasia, dysphonia, and hemoptysis. Physical examination findings suggesting acute laryngeal injury included pain on palpation of neck, swelling or edema of the neck, subcutaneous emphysema, and loss of landmarks in the neck. All four patients were admitted to the surgical intensive care unit and had the diagnosis of laryngeal fracture confirmed at laryngoscopy. Airway obstruction is a potential complication in all patients sustaining blunt laryngotracheal trauma. Early diagnosis and management may lead to a good outcome, as with these four patients.
Thoracic tracheobronchial rupture is rare in this country. Transection of the thoracic trachea is the least common of such injuries. Patients may present acutely, within hours of the accident, or after a delay of some weeks. Spreading subcutaneous emphysema or a persistent pneumothorax despite an intercostal drain are highly suggestive of the condition. Bronchoscopy provides the diagnosis. Early surgery produces good results in the absence of associated injuries. The purpose of this report is to bring the diagnosis to the attention of people involved in the immediate care of patients after major accidents. Bronchoscopy should be performed in all cases of major thoracic trauma.
The post-mortem findings of 4 sport divers involved in accidents showed air embolism of the heart as well as 2 subcutaneous emphysemas of shoulder and neck. The lungs were distended and the viscera were hyperaemic. The pleura showed petechiae and small patchy hemorrhages. In microscopic examination foci of alveolar hemorrhages of the lungs and, occasionally, muscosal rupture of small branches of the bronchial tree and of the bronchioli could be determined. The most likely causes for the accidents are discussed and special attention is given to panicking under water.
Neonatal tracheal injury represents a rare complication of endotracheal intubation. Previous case reports have demonstrated high morbidity and mortality (75%) associated with the rapid occurrence of subcutaneous emphysema, respiratory failure and death in this patient population. This mandates the prompt recognition, evaluation and management of this injury in the neonate. Although there is no clear consensus, previous authors have described both surgical therapy and expectant management. We report a case of a newborn who sustained tracheal rupture following traumatic intubation who survived with expectant management. The pathophysiology, management and indications for conservative management of neonatal tracheal rupture are reviewed.
We performed laparoscopically assisted percutaneous renal biopsy on 4 patients with azotemia or renal dysfunction who were believed to be unsuitable candidates for percutaneous renal biopsy. Tissue adequate for diagnosis was obtained in all 4 cases. Complications included subcutaneous emphysema in 1 patient and a small splenic capsular tear in 1, which was managed laparoscopically and did not require transfusion. Bleeding from the renal biopsy occurred in 1 patient and was easily managed laparoscopically. We recommend laparoscopically assisted percutaneous renal biopsy as an alternative method of renal biopsy in patients who can tolerate general anesthesia and who are not candidates for percutaneous renal biopsy.
Tracheocutaneous fistula is seen frequently in decannulated children and respiratory complications associated with primary surgical closure can be potentially fatal. Cough is a precipitating factor for an air leak and we report two cases in which this occurred. A tracheotomy was performed on a 5-month-old girl for mechanical ventilation. Decannulation was successful at the first attempt. One year later, she presented with a persistent tracheo-cutaneous fistula. After surgical closure without drainage, she developed subcutaneous emphysema during a coughing episode. Sutures were removed. A 9-month-old boy presented with oxygen-dependence after lung disease and a tracheotomy was performed for respiratory support. Decannulation was successful at the first attempt 6 months later. He developed a pneumomediastinum after surgical closure of a tracheo-cutaneous fistula. Sutures were removed but replacement of a tracheotomy tube was required. In both cases the wounds were allowed to heal by secondary intention.
Tracheostomy and gastrostomy are frequent adjunctive procedures required in the management of patients with severe brain injuries to facilitate neurorehabilitation. We therefore evaluated the use of two minimally invasive surgical procedures, percutaneous tracheostomy (PT) and percutaneous endoscopic gastrostomy (PEG), in 27 patients with severe brain injuries. The mean age was 41 +/- 4 years, and 23 (85%) were men. All patients were intubated, and 19 (70%) required mechanical ventilator support on the day of PT/PEG. The endotracheal tubes had been in place for 1 to 21 days (mean, 8.7 +/- 0.8). All patients were stable from their acute brain injury; 13 had intracranial pressure (ICP) monitors in place. The Seldinger technique, as described by Ciaglia, was employed for PT. Following PT, a PEG was inserted by a modification of the Sachs-Vine "push" technique. We were uniformly successful in placing these access tubes. Complications were minor and not clinically significant. Three of 13 patients (23%) with ICP monitors had a transient rise in ICP related to PT and one of these patients developed local subcutaneous emphysema. Another patient experienced a mild cellulitis at the tracheostomy site. Of note, there were no PEG-related complications. In conclusion, PT and PEG are readily learned, minimally invasive procedures. In our experience with patients with severe brain injuries combined PT/PEG is a uniformly safe alternative to gain long-term access to the airway and gut.