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Wed, 9 Jan 2002 00:50:05 -0000

Dear Ron,
We recently had a patient with a similar problem bilaterally. As you
suggest, whilst the lung was up and ventilation was effective, we simply
ignored the 'unsightly' surgical emphysema, as it causes few other problems.

Unfortunately, the emphysema eventually got so severe that there was a risk
of superficial skin breakdown and a severe reduction in chest wall
compliance, starting to effect ventilation. After some thought we inserted
two of our largest surgical drains into the subcutaneous tissues over the
anterior chest wall. The drains were intially connected to vacu-drains, but
they were so effective in removing the air that they filled very quickly. In
the end we connected the patient to low grade suction  (2-3 mmHg) through a
non-return valve.
Within 12 hours the emphysema had reduced by ~75%. The drains reamined
effective for over 4 days, until we were able to reduce veniltation
pressures and reduce the pleural leak.
Other patients that I have seen with very severe surgical emphysema after
tracheostomy problems, have been managed with no drains, without ill effect.
I have also seen one patient with marked swelling from severe surgical
emphysema, very effectively 'squashed' back to normal size in a hyperbaric
chamber (2-3 ATA) within ~3 hours. (Incidental benefit when treated for
another condition)
Hope that this helps
Good luck
Mark F
ITU Cons,UK
----- Original Message -----
From: "Ronald Simon" <Traumamd@nyc.rr.com>
To: "aast list" <trauma-l@lists.aast.org>; "CCM list" <ccm-l@list.pitt.edu>;
"trauma.org" <trauma-list@trauma.org>
Sent: Wednesday, January 09, 2002 12:05 AM
Subject: Venting subcutaneous emphysema

> I have a case i'd like your opinion on. Sorry for the multi listing but
> this problem crosses specialties.
>
> A 48 yo woman victim of MVC. Has multiple rib fx, pulm contusions, R
> pneumothorax for which a chest tube was placed. Patient now several days
> out chest tube still has small airleak, lung is up on chest xray. She
> has over the last few days developed significant subcut emphysema of her
> chest and face. My collegue wants to place a mediastinal "vent" (small
> incision above the manubrium to allow the air to escape). This does not
> make sense to me but in trying to be open minded i'm wondering if this
> is a described treatment. As far as i'm concerned as long as the chest
> tube is controlling the leak, the SQ air is unsightly and has no adverse
> effects unlike making a connection between the mediastinum and the
> outside world.
> Thanks for your input
> Ron Simon, MD
> Jacobi Medical Center
> Bronx, NY
>
>
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Venting subcutaneous emphysema