Subcutaneous Emphysema
Subcutaneous Emphysema
Subcutaneous Emphysema
PNEUMOMEDIASTINUM
SUBCUTANEOUS EMPHYSEMA
OBJECTIVES
General:
To present a case of a patient with Subcutaneous
Emphysema
Specific:
1. To present the history, physical examination findings
and diagnosis of a patient with Subcutaneous
Emphysema
2. To discuss Subcutaneous Emphysema, its presentation,
causes and pathophysiology
3. To discuss the appropriate management for a patient
with Subcutaneous Emphysema
GENERAL DATA
M.J.
45/F
Filipino
Married
Roman Catholic
Born and currently residing in GMA, Cavite
Admitted for the first time at DLSUMC on November 10,
2014 at around 2:00pm
CHIEF COMPLAINT
COUGH
1 month
PTA
3 weeks
PTA
2 weeks
PTA
1 week
PTA
3 days
PTA
1 day PTA
DOC
(-) hypertension
(-) diabetes mellitus
(-) asthma
(-) PTB
(-) allergies to food or medications
(-) previous hospitalization
FAMILY HISTORY
(-) hypertension
(-) diabetes mellitus
(-) asthma
(-) PTB
(-) cancer
(-) cardiac diseases
(-) renal diseases
MENSTRUAL HISTORY
OB-GYN HISTORY
G4P4 (4004)
No complications noted
REVIEW OF SYSTEMS
General: (+) weakness, (+) loss of appetite, (+) weight
loss (~50%), (-) easy fatigability
Integument: (-) pallor, (+) hyperpigmentation on cheeks
area (~1 year), (-) clubbing of nails, (-) lesions, (-) mass
Head and Neck: (-) dizziness, (-) headache, (-)
lymphadenopathy, (-) distention of veins
Eyes: (-) blurring of vision, (-) icteric sclerae, (-) redness,
(-) discharge
Ears: (-) tinnitus, (-) vertigo, (-) discharge
REVIEW OF SYSTEMS
Nose: (-) epistaxis, (-) discharge, (-) congestion, (-)
colds, (-) obstruction
Mouth and Throat: (-) sore throat, (-) hoarseness, (-)
dysphagia, (-) toothache
Cardiovascular: (-) chest pain, (-) palpitations
GIT: (-) diarrhea, (-) constipation, (-) abdominal pain
REVIEW OF SYSTEMS
GUT: (-) dysuria, (-) frequency, (-) hypogastric pain, (-)
flank pains
Hematologic: (-) easy bruising, (-) easy bleeding
Endocrine: (-) polydipsia, (-) polyphagia, (-) diaphoresis,
(-) heat/cold intolerance
Musculoskeletal: (+) joint pain (~3 years), (-) edema, (-)
fractures
Nervous: (-) paralysis, (-) syncope, (-) tremors, (-)
seizures
PHYSICAL EXAMINATION
General Survey
The patient is well developed, fairly nourished,
conscious, coherent, oriented to time, place and person,
ambulatory, in mild cardiorespiratory distress
Vital Signs
BP = 110/70 mmHg
HR = 108 bpm
RR = 26 cpm
Temp = 37.5C
PHYSICAL EXAMINATION
Integument
There was no pallor, erythema, jaundice. No mass or
lesions were noted. The patient is not febrile to touch.
The skin was neither warm nor cool to touch, no
excessive moisture or dryness and has good skin turgor.
PHYSICAL EXAMINATION
HEENT
(+) crepitus on the cheeks, neck and supraclavicular
area.
(+) erythematous, macular rashes localized on the
cheeks.
(+) asymmetry of the neck and cheeks: R>L.
Parotid glands and thyroid gland were not palpable. No
discharge noted from the eyes, ears and nose. Anicteric
sclerae and pink palpebral conjunctiva were noted. The
tonsils were non-hyperemic and non-hypertrophic
PHYSICAL EXAMINATION
Chest and Lungs
Inspection: There is symmetrical chest expansion. No
mass or lesions were noted. No retractions and
deformities were noted. No use of accessory muscles
were noted.
Palpation: There is noted point tenderness on anterior
chest wall as well as crepitus.
Percussion: Resonant on all lung fields.
Auscultation: There is noted basal crackles on the right
lung field.
PHYSICAL EXAMINATION
Cardiovascular
Inspection: No lesions and precordial bulging were
noted.
Palpation: Apex beat and PMI were both noted at the 5th
ICS LMCL. There were no heaves or thrills.
Auscultation: The heart rate is normal and has regular
rhythm. S1>S2 at the apex and S2>S1 at the base. No
murmurs were noted.
PHYSICAL EXAMINATION
Abdomen
Inspection: The abdomen is flabby and symmetrical. No
lesions, mass, visible pulsations and visible peristalsis
noted. The umbilicus is inverted.
Auscultation: Normoactive bowel sounds (10 bowel
sounds/minute).
Palpation: No tenderness noted.
Percussion: The abdomen was tympanitic all over.
PHYSICAL EXAMINATION
Extremities
There are full and equal peripheral pulses. No edema
and no limitation of movement noted.
PHYSICAL EXAMINATION
Neurologic
The patient is oriented to time, place and person. She
also has good recent, remote and immediate memory.
PHYSICAL EXAMINATION
Cranial Nerves
I
intact
II
(+) direct and consensual pupillary light reflex
III, IV, VI good extraocular muscle movement
V
good masseter contraction
VII
no facial asymmetry
VIII
no vertigo and hearing loss
IX, X (+) gag reflex
XI
good shoulder shrug
XII
tongue in midline.
(+) swelling of
the cheeks
(+) swelling of
the neck
Sinus Tachycardia
SALIENT FEATURES
4 weeks history of
productive cough with
yellowish phlegm
Swelling of
cheeks and
neck area
45/F
Crepitus on the cheeks,
neck, supraclavicular area
and bilateral lung fields
High grade
fever =
39.0C
PRIMARY IMPRESSION
Pneumomediastinum with Subcutaneous Emphysema
secondary to Alveolar Rupture secondary to Presumptive
Pulmonary Tuberculosis
T/C Systemic Lupus Erythematosus
BASIS
Suspicious densities in
both upper lungs
Short curvilinear
lucencies suggestive of
pneumomediastinum
Extensive subcutaneous
emphysema in
supraclavicular, axillary
areas and in both lateral
chest walls
Extensive subcutaneous
emphysema in the
submental, anterior,
posterior and lateral
neck regions
XRAY FINDINGS
(+) crepitus on
the cheeks, neck,
supraclavicular
area and bilateral
lung fields
(+) tenderness
on the anterior
chest wall
(+) basal
crackles on the
right lung
P.E. FINDINGS
HISTORY
DIFFERENTIAL DIAGNOSIS
RULE OUT
Cannot totally be ruled out
CHRONIC BRONCHITIS
RULE IN
(+) productive cough with yellowish
sputum
(+) dyspnea not usually
observed unless patient has COPD
or another condition that impairs
lung function
RULE OUT
(+) fever = 39.0C fever is
relatively unusual in Bronchitis
(-) use of accessory muscles
(-) radiologic findings
BRONCHIAL ASTHMA
RULE IN
(+) cough
(+) dyspnea
RULE OUT
(+) yellowish sputum
Cough occurs at any time of the
day In asthma, cough is usually
worse at night and patients typically
awake in the early morning hours
(-) wheezes
(-) rhonchi
BRONCHIECTASIS
RULE IN
(+) chronic productive cough with
yellowish sputum
(+) dyspnea
(+) weight loss
(+) basal crackles, right lung field
RULE OUT
(-) wheezes
(-) hemoptysis
(-) easy fatigability
(-) clubbing of the digits
(-) tram tracks on CXR
LUNG CARCINOMA
RULE IN
RULE OUT
(-) hemoptysis
(-) radiologic findings
1.
2.
3.
4.
Productive cough
Dyspnea
Fever of 37.8C
Difficulty of breathing
OBJECTIVE
ASSESSMENT
PLAN
1.
2.
3.
4.
IVF: PNSS 1L x 12 h
Blood work up: CBC, Na, K, BUN, Crea
Diagnostic: 12LECG, CXRAY PA, Sputum GS/CS, AFB x 2
Therapeutics: Levofloxacin 500 mg IV OD, Metoprolol
100mg/tab OD, Levopront 10ml TID, Cefipime 1gm IV Q8
()ANST, Vit B complex OD, Paracetamol 500 mg/ tab,
Paracetamol 300mg IV
5. O2 Support via nasal cannula at 2-3 lpm
6. WOF: chest pain, dyspnea, desaturation
1. Productive Cough
OBJECTIVE
ASSESSMENT
Pneumomediastinum with
Subcutaneous Emphysema secondary
to Alveolar Rupture secondary to
Presumptive PTB; T/C Systemic
Lupus Erythematosus
PLAN
1. Productive cough
2. Fever
OBJECTIVE
ASSESSMENT
PLAN
1. Productive cough
2. Fever
3. Subcutaneous emphysema
OBJECTIVE
ASSESSMENT
Pneumomediastinum with
Subcutaneous Emphysema secondary
to Alveolar Rupture secondary to PTB;
T/C Systemic Lupus Erythematosus
PLAN
1.
2.
3.
4.
5.
1. Productive cough
2. Dyspnea
OBJECTIVE
ASSESSMENT
PLAN
1. Productive cough
2. Fever
OBJECTIVE
ASSESSMENT
PLAN
1. Cough
2. Fever
3. Difficulty of breathing
OBJECTIVE
ASSESSMENT
PLAN
1. Fever
2. Cough
OBJECTIVE
ASSESSMENT
PLAN
1. Fever
2. Difficulty of breathing
OBJECTIVE
ASSESSMENT
PLAN
1.
2.
3.
4.
5.
6.
1. Fever
2. Productive cough
3. Difficulty of breathing
OBJECTIVE
ASSESSMENT
PLAN
1. Productive cough
2. Fever
3. Difficulty of breathing
OBJECTIVE
ASSESSMENT
PLAN
1.
2.
3.
4.
1. Fever
2. Productive cough
3. Difficulty of breathing
OBJECTIVE
ASSESSMENT
PLAN
1.
2.
3.
4.
IVF: PNSS 1L x 12
For 12LECG
Furosemide 40mg was given
Verapamil 2.5mg syrup 1 dose
given
5. FiO2 from 80% to 100%
6. Nebulized with Duavent x2 doses
7. For repeat Na,K, Crea
1. Fever
2. Productive cough
3. Difficulty of breathing
OBJECTIVE
ASSESSMENT
PLAN
1. IVF: PNSS 1L x 12
2. For blood transfusion of 1 unit
pRBC once available
3. Give Furosemide 40mg IV
4. Decrease FiO2 to 90%
1. Fever
2. Productive cough
3. Difficulty of breathing
OBJECTIVE
ASSESSMENT
PLAN
1. IVF: PNSS 1L x 16
2. Given Furosemide 2g IV
3. Decrease PEEP to12
1. Fever
2. Productive cough
3. Difficulty of breathing
OBJECTIVE
ASSESSMENT
PLAN
1. Productive cough
2. Difficulty of breathing
OBJECTIVE
ASSESSMENT
PLAN
1. Increase Norepinephrine
20ugtts/min
2. Decrease PEEp to 8
3. For ABG
4. For Na,K,
5. NaCHo3 SIVP was given
FINAL DIAGNOSIS
Acute Respiratory Failure Type II secondary to
Community-Acquried Pneumonia, High Risk
Pneumomediastinum with Subcutaneous Emphysema,
resolving
Clinically-diagnosed Pulmonary Tuberculosis
Systemic Lupus Erythematosus
CASE DISCUSSION
DEFINITION
Type I
Type II
Type III
Type IV
Serositis
Oral ulcers
Arthritis
Photosensitivity
Blood/Hematologic disorder
Renal disorder
ANA (+)
Immunologic disorder
Neurologic disorder
Malar rash
Discoid rash
MANAGEMENT OF SLE
Analgesics and antimalarials are the mainstays of
treatment for mild disease
Systemic steroids are the mainstays of severe disease
PNEUMOMEDIASTINUM;
SUBCUTANEOUS
EMPHYSEMA
OVERVIEW
Subcutaneous emphysema is characterized by painless
swelling of the tissues because of air tracking along
tissue planes. It is commonly seen over the chest wall
around drain sites, in the head and neck.
Palpation elicits a characteristic tissue paper feeling
beneath the fingers. Air may track deeper into the
mediastinum, retroperitoneum, scrotum, and down into
the limbs.
OVERVIEW
In pneumomediastinum, there is gas in the interstices of
the mediastinum. Typically, there is severe substernal
chest pain with or without radiation into the neck and
arms.
The diagnosis is confirmed with the chest radiograph.
Usually no treatment is required, but the mediastinal air
will be absorbed faster if the patient inspires high
concentrations of oxygen. If mediastinal structures are
compressed, the compression can be relieved with
needle aspiration.
PATHOPHYSIOLOGY
The three main causes are:
1. Alveolar rupture with dissection of air into the
mediastinum
2. Perforation or rupture of the esophagus, trachea, or
main bronchi
3. Dissection of air from the neck or the abdomen into
the mediastinum.
CAUSES
Forceful coughing, crying, or shouting may elevate
pressures. Vomiting, defecation, and Valsalva maneuver
may elevate pulmonary alveolar pressures, as may illicit
drug use, especially if associated with coughing.
Strenuous athletic activity, diving, flying, playing musical
instruments, and childbirth are also potential risk factors.
CAUSES
Obstructive lung disease (eg, asthma, bronchiolitis,
foreign body aspiration, bronchopulmonary dysplasia),
especially in intubated and mechanically ventilated
patients, is a risk factor.
Respiratory tract infections, especially if associated with
asthma, may predispose a patient to the development of
a pneumomediastinum.
MANAGEMENT
Diagnostic
Chest radiography usually reveals a
pneumomediastinum. Chest radiography reveals air
within the mediastinal space. Coexisting disease (eg,
pneumothorax, pneumoperitoneum,
pneumoretroperitoneum of pneumopericardium) may
also be evident.
MANAGEMENT
Radiolucent streaks representing free air may be
observed tracking along the margins of the heart, within
the retrosternal space, or surrounding the trachea.
Typical features of pneumomediastinum seen on chest
radiography are caused by air outlining normal anatomic
structures as it tracks from the mediastinum producing
the thymic sail sign, "ring around the artery" sign, tubular
artery sign, double bronchial wall sign, continuous
diaphragm sign, and the extrapleural sign.
MANAGEMENT
Therapeutic
The tissues in the mediastinum will slowly resorb the air
in the cavity so most pneumomediastinums are treated
conservatively. Breathing high flow oxygen will increase
the absorption of the air.
If the air is under pressure and compressing the heart, a
needle may be inserted into the cavity, releasing the air.
Surgery may be needed to repair the hole in the trachea,
esophagus or bowel.
MANAGEMENT
If there is lung collapse, it is imperative the affected
individual lies on the side of the collapse, although
painful, this allows full inflation of the unaffected lung.
REFERENCES
Longo, D., Fauci, A., et.al., 2012. Harrisons Principles of
Internal Medicine, 18th edition, McGraw-Hill Companies,
Inc., USA
http://www.emedicine.medscape.com
http://
www.nlm.nih.gov/medlineplus/ency/article/003286.htm
THANK YOU