What are the indications for creating gill slits in cases of subcutaneous emphysema?

Indications for Gill Slits in Subcutaneous Emphysema

Gill slits (bilateral infraclavicular or supraclavicular skin incisions) are indicated for life-threatening subcutaneous emphysema causing acute airway obstruction, thoracic compression with respiratory compromise, or tension physiology interfering with cardiopulmonary resuscitation. 1, 2, 3

When to Perform Gill Slits

Life-Threatening Situations Requiring Immediate Intervention:

• Acute airway obstruction from massive subcutaneous emphysema causing respiratory distress 1, 2
• Cardiac arrest where subcutaneous emphysema interferes with effective cardiopulmonary resuscitation 4
• Tension physiology with impaired cardiovascular and pulmonary function requiring immediate decompression 4
• Severe thoracic compression leading to respiratory failure despite other interventions 1, 3

Clinical Signs Indicating Need for Intervention:

• Palpable cutaneous tension with progressive crepitus 5
• Dysphagia or dysphonia from neck involvement 5
• Palpebral closure from facial involvement 5
• Stridor, accessory muscle use, or signs of respiratory distress 2
• Failure of conservative management with rapid progression 6, 5

Conservative Management Should Be Attempted First

Most subcutaneous emphysema is self-limited and requires no direct intervention, resolving within days. 1, 3, 6

Initial Management Steps:

• Immediately unclamp any chest tube if clamped, as this is a common reversible cause 1, 2, 3
• Check for tube malposition, kinking, or blockage and ensure proper function 2, 3
• Verify the tube is connected to underwater seal drainage kept below chest level 2
• Consider replacing a small tube with larger bore if there is a massive air leak 1

Alternative Techniques to Gill Slits

Recent evidence supports less invasive approaches that may be attempted before resorting to gill slits:

Percutaneous Angiocatheter Decompression (Preferred Initial Approach):

• Place multiple 14G angiocatheters into the subfascial space of the anterior chest wall 7, 6
• This technique provides rapid decompression with complete resolution in <24 hours 6
• Superior to large open incisions with better tolerability, lower cost, and simpler procedure 6
• Minimal complications compared to open techniques 7, 6

Large-Bore Subcutaneous Drain:

• Insert 26 French fenestrated intercostal catheter subcutaneously 5
• Maintain on low suction (-5 cm H₂O) for 24 hours 5
• Effective for extensive emphysema without requiring open incisions 5

Modified Gill Slits with Negative Pressure Wound Therapy:

• For ventilator-dependent patients with ongoing air formation 8
• 2-3 cm blowhole incision in supraclavicular/infraclavicular area with NPWT applied 8
• Mean duration 7.5 days with no wound infections reported 8

Critical Pitfalls to Avoid

• Never clamp a bubbling chest tube as this converts simple pneumothorax to life-threatening tension pneumothorax 1, 2, 3
• Do not delay intervention in true life-threatening cases while attempting conservative measures 4
• Ensure underlying pneumothorax is adequately drained, as this is the source of ongoing air 1, 2
• Use strict aseptic technique with any intervention to prevent infection 1

Practical Algorithm

1. Assess severity: Life-threatening (airway obstruction, cardiac arrest, tension physiology) vs. non-life-threatening
2. If non-life-threatening: Optimize chest tube function, observe for spontaneous resolution
3. If severe but not immediately life-threatening: Attempt percutaneous angiocatheter decompression first 7, 6
4. If life-threatening with failed angiocatheter or during active CPR: Perform gill slits immediately 4
5. If ventilator-dependent with ongoing formation: Consider gill slits with NPWT 8