What are the management strategies for crepitus (subcutaneous emphysema) versus hematoma post intubation complications?

Management of Crepitus vs Hematoma Post Intubation Complications

The management of subcutaneous emphysema (crepitus) and hematoma post-intubation requires distinct approaches, with subcutaneous emphysema typically managed conservatively while hematomas often require immediate surgical evacuation when causing airway compromise.

Subcutaneous Emphysema (Crepitus) Management

Initial Assessment

• Assess for key symptoms including crackling sensation when touching affected area (crepitus), respiratory distress, stridor, obstructed breathing patterns, and agitation 1
• Evaluate for pneumothorax, pneumomediastinum, or displaced tracheal fragments through chest X-ray 1
• Monitor for signs of mediastinitis (severe sore throat, deep cervical pain, chest pain, dysphagia, painful swallowing, fever) 2

Treatment Algorithm

1. Secure the airway - this is the primary concern 1

   • Administer high-flow humidified oxygen 1
   • Position patient upright (35° head-up) to reduce airway edema 1
   • Continuous monitoring with capnography and pulse oximetry 1

2. Conservative management for mild to moderate cases 3, 4

   • Close observation for respiratory deterioration 1
   • Prophylactic antibiotics to prevent infection 4
   • Avoid activities that increase pressure (forced glottic closure, coughing) 4

3. For severe cases with respiratory compromise 1

   • Consider videolaryngoscopy if intubation is needed 1
   • Avoid positive pressure ventilation if possible as it may worsen air leaks 1
   • Tracheostomy may be necessary in cases of upper tracheal injury 1

4. Medication management

   • Intravenous corticosteroids (dexamethasone) for at least 12 hours to reduce airway edema 1, 5
   • Multimodal pain management 1

Hematoma Management

Initial Assessment

• Evaluate for signs of airway compromise: stridor, difficulty breathing, arterial oxygen desaturation 2
• Assess hematoma size, location, and rate of expansion 2
• Monitor vital signs for signs of hemodynamic instability 2

Treatment Algorithm

1. For hematoma with airway compromise 2

   • Implement the SCOOP approach: Skin exposure; Cut sutures; Open skin; Open muscles; Pack wound 2
   • Local anesthetic infiltration is not required when opening the wound 2

2. If evacuation fails to stabilize the patient 2

   • Consider emergency tracheal intubation with videolaryngoscopy 2
   • Use a smaller tracheal tube and/or adjuncts such as a bougie 2
   • Confirm successful intubation with capnography 2

3. For cannot intubate, cannot oxygenate situations 2

   • Proceed to front-of-neck airway access 2
   • Scalpel cricothyroidotomy or emergency tracheostomy are preferred to cannula cricothyroidotomy 2
   • Emergency front-of-neck airway equipment must be immediately available 2

4. For stable hematomas without airway compromise 6

   • Close observation and monitoring 2
   • Position patient in 35° head-up position 5

Key Differences in Management

• Subcutaneous emphysema: Typically managed conservatively with observation, prophylactic antibiotics, and avoiding activities that increase pressure 3, 4, 7
• Hematoma: Often requires immediate surgical evacuation when causing airway compromise 2

Post-Treatment Care

• Close observation for signs of respiratory deterioration 1
• Regular assessment of airway patency 1
• Monitoring for signs of infection or mediastinitis 2, 1
• Maintain head-up positioning to reduce airway edema 1, 5
• Avoid unnecessary positive fluid balances 1
• Deep breathing exercises to improve respiratory function 1
• Create an airway alert in the patient's medical record if future airway management is anticipated to be difficult 1

Warning Signs Requiring Immediate Intervention

• Progressive respiratory distress 1
• Increasing subcutaneous emphysema 1
• Development of fever or signs of infection 1
• Any patient who complains of difficulty breathing, even if objective signs are absent 1
• Ongoing bleeding or expanding hematoma 2