Things not to miss - Subcutaneous emphysma
An elderly male patient was transferred to medical casualty ward in the evening with a history of severe left sided chest pain for last 2 hours. It was revealed that in fact the patient got the pain only after he had fallen at home and the chest impacted on nearby chair. The pain was of pleuritic nature.
On examination the patient was hemodynamically stable and the saturation was 100%. House officer noted some crepitus over the painful area. Air entry was symmetrical. He prescribed analgesics and ordered a Chest Xray.
Several hours later the house officer was called to see the patient by the nursing officer as the patient was complaining of increasing shortness of breath. The patient was very restless and was dyspnoeac. Oxygen saturation was 89%. House officer noted his chest to be swollen and the crepitus was extending up to neck. His Xray which was taken few hours before was on the bed side table.
The registrar was summoned immediately and with the help of the surgical team an intercostal tube was inserted. Patient made a complete recovery.
Lesson
~ Air trapped within the subcutaneous tissue is termed subcutaneous emphysema. It is felt as crepitus.
~ It's always important to look for subcutaneous emphysema in patients coming after trauma.
~ In the setting of a trauma subcutaneous emphysema almost always indicates air leak from lungs. Or in other words a pneumothorax!
~ It's always safer to insert an IC tube as the pneumothorax may be small and not visible in the initial Xray. But with time it can expand and result in life threatening tension pneumothorax. So the moment you notice subcutaneous emphysema, get a senior to see the patient urgently.
~ As a house officer if you ordered a special investigation ALWAYS MAKE SURE YOU SEE IT!
It's not nice to have a Xray of a pneumothorax not seen by a doctor with the patient.
~ On busy casualty nights you may forget to see or the nurses might forget to show you. Have your own methods so that you won't miss a pneumothorax in a Xray, hyperkalemia in a report or a STEMI on an ECG.
eg:
1. Ask the patient to immediately show the Xray the moment it is taken. It's very unlikely that a patient will forget to show it to you!
2. Ask the nurses to show you all imaging/ ECGs/Blood reports etc to you before handing it over to the patient or attaching to the BHT.
(The photo was taken from Internet)
On examination the patient was hemodynamically stable and the saturation was 100%. House officer noted some crepitus over the painful area. Air entry was symmetrical. He prescribed analgesics and ordered a Chest Xray.
Several hours later the house officer was called to see the patient by the nursing officer as the patient was complaining of increasing shortness of breath. The patient was very restless and was dyspnoeac. Oxygen saturation was 89%. House officer noted his chest to be swollen and the crepitus was extending up to neck. His Xray which was taken few hours before was on the bed side table.
The registrar was summoned immediately and with the help of the surgical team an intercostal tube was inserted. Patient made a complete recovery.
Lesson
~ Air trapped within the subcutaneous tissue is termed subcutaneous emphysema. It is felt as crepitus.
~ It's always important to look for subcutaneous emphysema in patients coming after trauma.
~ In the setting of a trauma subcutaneous emphysema almost always indicates air leak from lungs. Or in other words a pneumothorax!
~ It's always safer to insert an IC tube as the pneumothorax may be small and not visible in the initial Xray. But with time it can expand and result in life threatening tension pneumothorax. So the moment you notice subcutaneous emphysema, get a senior to see the patient urgently.
~ As a house officer if you ordered a special investigation ALWAYS MAKE SURE YOU SEE IT!
It's not nice to have a Xray of a pneumothorax not seen by a doctor with the patient.
~ On busy casualty nights you may forget to see or the nurses might forget to show you. Have your own methods so that you won't miss a pneumothorax in a Xray, hyperkalemia in a report or a STEMI on an ECG.
eg:
1. Ask the patient to immediately show the Xray the moment it is taken. It's very unlikely that a patient will forget to show it to you!
2. Ask the nurses to show you all imaging/ ECGs/Blood reports etc to you before handing it over to the patient or attaching to the BHT.
(The photo was taken from Internet)
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