“gills” procedure for subcutaneous emphysema

4 Dec

neat case report in a recent JEM:

 

THE CASE:

56 yo male, perforated duodenal ulcer with massive subcutaneous emphysema (neck and chest wall) and pneumomediastinum

 

patient coded, abd distention increased with chest compressions and bag-mask ventilation, face and neck swelling worsened

 

caused tension physiology, with trapped subcut air causing resistance to lung filling

 

WHAT THEY DID:

bilateral horizontal slits ~3cm long over the clavicle, into the fascia (“gills”)

subcut

WHAT HAPPENED?

immediate bubbling, decreased subcut air

improved ventilation, pulses returned

air continued to leak out of these “gills” over the next several hours

suture closed for hemostasis the next day without reaccumulation of subcut air

 

OTHER STUFF THAT’S BEEN DONE:

infraclavicular incisions through skin

anterior midchest JP drains

fenestrated angiocath to drain/stent open gill incisions

chest tubes, for pneumothorax, of course, but the problem’s not pleural (e.g. perf ulcer), may not cure it

 

BOTTOM LINE:

in a pinch, with severe subcut air, “gills” procedure (incisions over clavicles) might be worth a try

 

References: article; picture

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