Subcutaneous Emphysema
	Date: Sun, 01 Jun 1997 22:09:41 +0800 From: Jack [cfchong@ms12.hinet.net] I had a case of spontaneous tension pneumothorax who collapsed just after arrival at our ED; he suffered from VT/VF during resuscitation ( intubation, needle decompression, followed by chest-tube insertion ). He's improving after the resuscitation ( with spontaneous movements and eyes opening ) but still can't obey orders. The big question is that the patient had severe subcutaneous emphysema ( from face to fingers and scrotum ). How would you guys treat such ccondition ? ( He is now on chest-tube connected to low-pressure suction with continuos air leakage ). Our chest surgeon said "keep observation". Any opinion is highly appreciated.
	Date: Sun, 1 Jun 1997 13:42:44 -0400 (EDT) From: Ken Mattox [KMATTOX@aol.com] As a surgeon who has seen many of these over the years, just keep observing and do not let anyone OVERTREAT. Assure that you do not have the patient on PEEP or high inspiratory pressures on the ventilator. Put him on spontaneous, rather than controlled ventilation if possible...Assure the family. Be patient
	Date: Sun, 1 Jun 97 15:36:48 -0500 From: Andy Fragen [afragen@CCTR.UMKC.EDU] I agree 100% with your chest surgeon. As unsightly as it may seem the SQ emphysema will resorb once the air leak has resolved. Some will argue for either higher suction using the Emerson system, though others feel that this may keep the air leak open. Others would go with water seal only, as long as their is no pneumothorax on CXR. I would keep enough suction on the patient to maintain small or no residual pneumothorax and if high suction is required place a 2nd chest tube. These lessons learned from taking care of those Lung Volume Reduction patients. YMMV. Andy Fragen Chief Resident, UMKC Kansas City, MO
	Date: Mon, 2 Jun 1997 10:25:35 -0400 From: Smith, J. Stanley, MD [JStanley.Smith@hmc.psu.edu] With such prominent subcut emphysema, you must consider a tracheal/bronchial disruption or injury. He should have a bronchoscopy and possibly a thoracotomy. Also use Pressure-controlled ventilation to limit inspiratory pressure.
	Date: Tue, 03 Jun 1997 00:14:26 +0200 From: Teddy Fagerström [teddy.f@swipnet.se] Had one iatrogenous "full body" emphysema, caused by tracheostomy. She was only "treated" with expectance, with full recovery. Teddy
	Date: Mon, 2 Jun 1997 21:22:15 -0400 From: Jean Péloquin [jean.peloquin@chg.ulaval.ca] This situation suggest that one looks for: 1-ruptured major bronchus 2 - bullous emphysema 3-Simple pulmonary wound with extensive pleural adhesions JP
	Date: Wed, 04 Jun 1997 22:21:23 +0800 From: Jack [cfchong@ms12.hinet.net] The SQ emphysema is resolving rapidly after the chest tube sealed off. He is also recovering from the hypoxic encephalopathy caused by cardiac arrest during tension pneumothorax. Thanks to everybody who cares.