Question 26

College Answer

Resuscitation if required. Is airway OK, is she being ventilated adequately, Is circulation intact?

Work out reason: Is it ventilator, tubing or patient. ie barotrauma, new tracheostomy or CVC, pneumothorax,

So, examine patients, get urgent CXR, insert chest drain if required, consider new ventilation strategy.

Discussion

The college answer leaves much to be desired.

This question would benefit from a systematic approach.

Thus, one would approach this patient by an immediate attention to the ABCs, whicle simultaneouesly performing a focused physical examination, and retrieving a focused history of recent events from attending nursing and medical staff.

• Immediate management:
  • Increase FiO2 to 100%
  • Give a bolus of sedation and administer a neuromuscular junction blocker
  • Disconnect the patient from the ventilator and bag them manually to assess lung compliance
• Airway:
  • Inspect ETT to ensure it has not slipped too far inside the patient, into the right main bronchus.
  • Confirm bilateral air entry by auscultation
• Breathing:
  • Inspect palpate and auscultate the chest, looking for pneumothorax
  • CXR: inspect for pneumothorax, mediastinal gas and subdiaphragmatic gas
• Circulation:
  • Assess hemodynamic stability and administer a rescue fluid blous as well as inotropes/vasopressors as appropriate, while working to diagnose and manage the cause of the problem.
  • Ask about recent procedures, particularly central line insertion, recent routine pressure area care rolls, naso/orogastric tube insertions and airway manipulation
• Specific management
  • Insert unilateral or bilateral chest drains, as indicated by CXR
  • Consider dual-lumen intubation and lung isolation in the event of trachoebronchial tree disruption
    • urgent cardiothoracic surgical consultation if this is the case
    • urgent general or upper GI surgical consultation if oesophageal, gastric or intestinal perforation is thought to be the cause
  • Keep FiO2 high to aid in the resorption of surgical emphysema
  • Consider subcutaneous Penrose drains or infraclavicular incisions down to pectoralis fascia to assist in the clearance of surgical emphysema (if it is posing a threat to the patient's stability, and only after surgcal consultation)
  • Minimise positive pressure of ventilation if pneumothorax or bronchopleural fistula is implicated

Aghajanzadeh, Manouchehr, et al. "Classification and Management of Subcutaneous Emphysema: a 10-Year Experience." Indian Journal of Surgery(2013): 1-5.

ZIMMERMAN, JACK E., BURDETT S. DUNBAR, and HERMAN C. KLINGENMAIER. "Management of subcutaneous emphysema, pneumomediastinum, and pneumothorax during respirator therapy." Critical care medicine 3.2 (1975): 69-73.

Woehrlen Jr, Arthur E. "Subcutaneous emphysema." Anesthesia progress 32.4 (1985): 161.

Jairo I. Santanilla "The Crashing Ventilated Patient"; Chapter 3 in Emergency Department Resuscitation of the Critically Ill, American College of Emergency Physicians, 2011.