What is the immediate management for a patient with Grave's disease who develops subcutaneous emphysema after Central Venous Catheter (CVC) insertion and is at risk of impending thyroid storm?

Immediate Management of Subcutaneous Emphysema After Central Line Insertion in Grave's Disease with Impending Thyroid Storm

Immediately assess for airway compromise and tracheal injury, administer high-flow oxygen, position the patient head-up, and prepare for emergency surgical airway if signs of respiratory distress develop, while simultaneously initiating aggressive medical management of impending thyroid storm. 1, 2

Critical Initial Assessment and Stabilization

Airway evaluation takes absolute priority given the dual threat of subcutaneous emphysema progression and thyroid storm-related airway compromise:

• Administer supplemental high-flow oxygen immediately and position the patient in a head-up position to optimize airway patency and reduce airway edema 1, 2
• Assess for signs of airway compromise using the DESATS criteria: Difficulty swallowing/discomfort, increase in Early warning score, Swelling, Anxiety/agitation, Tachypnea/difficulty breathing, and Stridor 3, 2
• Ensure portable lighting is available for adequate visualization of the neck 1, 2
• Immediately call for senior anesthesia and surgical support if any signs of airway compromise are present 1, 2

Critical Pitfall

Stridor is a late sign of airway compromise and intervention should not be delayed until stridor develops—act on earlier signs of respiratory distress 2

Determine Source and Extent of Subcutaneous Emphysema

The subcutaneous emphysema following central line insertion suggests either:

• Pneumothorax with tracking of air into neck tissues
• Direct tracheal injury during attempted central line placement (particularly if internal jugular or high subclavian approach was used) 4

Immediate diagnostic steps:

• Obtain urgent chest X-ray to evaluate for pneumothorax and mediastinal air
• Perform flexible endoscopic laryngeal assessment by an experienced operator to evaluate for tracheal injury and airway patency 1, 2
• Increase frequency of observations with continuous monitoring of respiratory status 3

Airway Management Algorithm

If Signs of Airway Compromise Present:

Immediately notify senior anesthetist and prepare for emergency airway intervention 1, 2:

1. If rapidly expanding neck swelling with respiratory distress: Consider immediate intubation before complete airway obstruction occurs
2. Use videolaryngoscopy at first intubation attempt to maximize success 2
3. Limit intubation attempts—multiple attempts worsen outcomes 2
4. If cannot intubate, cannot oxygenate (CICO) situation develops: Proceed immediately to scalpel cricothyroidotomy 1

Scalpel Cricothyroidotomy Technique (if CICO occurs):

This is the recommended emergency front-of-neck airway (FONA) technique 1:

• Maximum neck extension (if no cervical spine concerns)
• Horizontal incision with wide scalpel blade (size 10 or 20) through cricothyroid membrane
• Insert bougie as guide for 5.0-6.0 mm cuffed tracheal tube 1
• Avoid transtracheal jet ventilation (TTJV) as it has high failure rates, causes barotrauma, and subcutaneous emphysema hinders later open approaches 1

If No Immediate Airway Compromise but Concerns Raised:

• Arrange immediate senior surgical review 1
• Consider intravenous dexamethasone to improve upper airway obstruction and edema (though effect is not immediate) 1
• Transfer to ICU or post-anesthesia care unit for close observation 1, 3

Simultaneous Management of Impending Thyroid Storm

While securing the airway, initiate aggressive medical management of thyroid storm:

Antithyroid Drug Therapy:

• Propylthiouracil (PTU) is preferred in thyroid storm as it inhibits peripheral conversion of T4 to T3 5
• Loading dose: PTU 500-1000 mg orally or via nasogastric tube, then 250 mg every 4 hours 5
• Alternative: Methimazole if PTU contraindicated, but monitor for angioedema which can worsen airway compromise 6

Additional Medical Management:

• Beta-blockade (propranolol or esmolol) for heart rate and blood pressure control, but use cautiously if hemodynamic instability or heart failure present 7, 8
• Inorganic iodide (given 1 hour after antithyroid drug to prevent organification)
• Corticosteroids (hydrocortisone or dexamethasone) 8, 9
• Supportive care: cooling measures, fluid resuscitation, treatment of precipitating factors

Critical Consideration:

If hepatic dysfunction develops or patient cannot tolerate antithyroid drugs, consider continuous renal replacement therapy (CRRT) which can stabilize vital signs and lower thyroid hormone levels 7

Management of Confirmed Tracheal Injury

If tracheal rupture is identified (rare but reported complication) 4:

• Surgical exploration and primary repair is required
• Maintain airway with endotracheal tube positioned distal to injury if possible
• Broad-spectrum antibiotics to prevent mediastinitis
• Monitor for signs of mediastinitis: severe sore throat, deep cervical pain, chest pain, dysphagia, fever 2

Post-Stabilization Care

• Transfer to level 2 or 3 care for close postoperative observation 2
• Maintain head-up positioning and avoid unnecessary positive fluid balances to reduce airway edema 2
• Serial chest X-rays to monitor pneumothorax or pneumomediastinum progression
• Continue aggressive thyroid storm management until clinical improvement documented

Key Clinical Pitfalls to Avoid

• Do not delay airway intervention waiting for "definitive" diagnosis—act on clinical signs of compromise 2
• Do not perform multiple intubation attempts—early progression to surgical airway saves lives 2
• Do not use beta-blockers indiscriminately in thyroid storm with poor cardiac function or hypotension 8
• Do not assume subcutaneous emphysema is benign—it may herald tracheal injury requiring urgent surgical intervention 4