What is the management of subcutaneous emphysema post injury?

Management of Subcutaneous Emphysema Post Injury

Subcutaneous emphysema following trauma should be managed by immediately addressing the underlying cause, ensuring airway patency, and providing appropriate respiratory support while avoiding interventions that may worsen air leakage.

Initial Assessment and Management

• Assess airway patency and breathing status immediately, as subcutaneous emphysema can be associated with respiratory compromise 1
• Look for clinical signs of respiratory distress including stridor, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession 1
• Provide high-flow oxygen to both face and tracheostomy (if present) when available 1
• Evaluate the extent and progression of subcutaneous emphysema through physical examination (crepitus on palpation) 1
• Identify the underlying cause, which may include:
  • Pneumothorax 1
  • Tracheobronchial injury 1
  • Chest tube malfunction (kinked, blocked, or clamped) 1
  • Maxillofacial trauma 2
  • Iatrogenic causes (post-procedure) 1

Diagnostic Workup

• Obtain chest radiography to detect pneumothorax, pneumomediastinum, or other thoracic injuries 1
• Consider CT scan with contrast enhancement for more detailed assessment of the injury and extent of air collection 1
• Use waveform capnography when available to assess airway patency 1
• Laboratory tests should include inflammatory markers (WBC, CRP) to evaluate for potential infection 1

Specific Interventions

For Pneumothorax-Related Subcutaneous Emphysema:

• If a chest tube is already in place and subcutaneous emphysema develops:

  • Immediately unclamp the tube if it was clamped 1
  • Check for tube patency, kinking, or displacement 1
  • Ensure proper tube function and connection to drainage system 1

• If no chest tube is present and pneumothorax is detected:

  • Insert a small-bore chest tube (10-14F) as there is no evidence that larger tubes (20-24F) are more effective 1, 3
  • Place the tube in the appropriate intercostal space (typically 5th intercostal space, mid-axillary line) 3
  • Use proper aseptic technique to minimize infection risk (reported at 1%) 1, 3

For Tracheostomy-Related Subcutaneous Emphysema:

• Assess tracheostomy tube patency and position 1
• If the tube is blocked or displaced, perform an emergency tube change following established protocols 1
• Avoid attempting ventilation through a displaced tracheostomy tube as this can worsen subcutaneous emphysema 1

For Extensive or Progressive Subcutaneous Emphysema:

• For severe cases with respiratory compromise, consider direct decompression techniques:
  • Percutaneous angiocatheter decompression in the subcutaneous tissue (less invasive approach) 4
  • Surgical decompression for rapidly progressing cases with impending respiratory failure 5

Ongoing Management

• Provide close monitoring of respiratory status and progression of subcutaneous emphysema 1, 6
• Continue oxygen therapy as needed based on oxygen saturation 1
• Treat underlying cause (pneumothorax, tracheal injury) appropriately 1
• Consider antibiotics only if there is evidence of infection or in cases of penetrating trauma 5
• The average resolution time for subcutaneous emphysema varies depending on the underlying cause and management approach 6

Special Considerations

• Extensive subcutaneous emphysema extending to limbs may indicate severe underlying chest injury requiring urgent intervention 7
• In cases of maxillofacial trauma, even minor injuries can lead to significant subcutaneous emphysema extending to the neck and mediastinum 2
• Avoid clamping chest tubes that are still bubbling as this may convert simple pneumothorax into tension pneumothorax 1

Pitfalls to Avoid

• Never clamp a bubbling chest tube as this can convert a simple pneumothorax into a life-threatening tension pneumothorax 1
• Avoid attempting ventilation through a displaced tracheostomy tube or into a false passage 1
• Do not delay treatment of the underlying cause, as rapidly expanding subcutaneous emphysema can lead to respiratory compromise 7
• Remember that subcutaneous emphysema may be a sign of a more serious underlying injury requiring prompt intervention 7