Compressed air injury to the esophagus: case report

Compressed air injuries to the esophagus are uncommon. They characteristically present with respiratory distress, subcutaneous and mediastinal emphysema, and may have a pneumothorax. The distal esophagus is always the site of rupture and requires prompt surgical repair to avoid serious morbidity and potential lethal complications.     

High-pressure air-blast injury of the esophagus

Blast injuries causing pneumatic damage to the oesophagus are very rare. Patients usually present with respiratory distress, subcutaneous and mediastinal emphysema, and may also have pneumothorax. Ruptures need early repair to avoid serious morbidity and potential lethal complications. We report about a successfully treated 47-year-old patient, who has been admitted to our department with compressed air injury of the oesophagus.     

Pneumothorax, subcutaneous emphysema and mediastinal emphysema in transnasally intubated patients

A 41-year-old woman was admitted to our clinic because of an acute subdural hematoma. After an emergency operation her neurological status improved with an increase in the Glasgow Coma Scale score from 6 to 11. On the second postoperative day she developed frequent episodes of clonic convulsive seizures localized in the face and the left upper extremity, and her level of consciousness deteriorated. Next day she was transnasally intubated for respiratory management, but no mechanical ventilation was required. While she was undergoing the CT scanning 5 days after intubation, respiratory arrest and cyanosis developed all of a sudden, and her face and neck became swollen. The chest x-ray revealed a marked subcutaneous emphysema, mediastinal emphysema and bilateral pneumothorax. CT at that time showed a diffuse low density area in the right hemisphere, and a marked midline shift returned. She did not regain consciousness and died 12 days after the incident. At autopsy an ulcer was observed in the wall of the trachea, where the tip or the cuff of the transnasal tracheal tube was supposed to be present. No perforation, however, was there. Case 2: A 75-year-old woman was admitted to our hospital because of SAH. In hospital course she was also transnasally intubated and required no mechanical ventilation. When she was undergoing the CT scanning 3 days after intubation, she developed subcutaneous and mediastinal emphysema similarly to case 1. Although it is reported to be not a rare complication in patients on a mechanical ventilator, subcutaneous emphysema or pneumothorax is extremely rare in those intubated patients with spontaneous respiration. The mechanism of these complications in these cases is briefly discussed.     

Diagnosis, procedures and conservative therapy of a bronchial rupture after intubation with double-lumen tube

Bronchial rupture is a rare but severe complication of intubation with a double-lumen tube. Cardinal symptoms are mediastinal and subcutaneous emphysema as well as pneumothorax. Larger injuries result in an air leak and the endtidal carbon dioxide decreases. The gas exchange may worsen drastically when mucosal prolapse or bronchial haemorrhagia lead to bronchial occlusion. Mediastinitis or sepsis can be the sequel of the opened mediastinum. If bronchial injury is suspected probably fibreoptic bronchoscopy is indicated. We report on a case of bronchial rupture due to overinflation of the endobronchial cuff or movement of the inflated cuff when repositioning the patient. The conservative therapy was successful in spite of the fact that surgical intervention is recommended in the literature following bronchial rupture. To avoid tracheobronchial injuries an adequate tubus size must be selected. The more flexible polyvinylchloride (PVC) tubes without a carinal hook should be preferred to the Carlens tube. An atraumatic intubation is promoted by leaving the stylet inside after the tip of the tube has passed the vocal cords. To identify the minimum occlusive pressure of the endobronchial cuff for lung isolation different methods are described and should be used. The cuff has to be deflated when the patient is repositioned and when one-lung-ventilation is not required. Tumours of the tracheobronchial tree and weakness of the bronchial wall caused by steroid hormone therapy or COPD may increase the risk of tracheobronchial laceration.     

Unusual complications of laparoscopic totally extraperitoneal inguinal hernia repair

Although complications of laparoscopic totally extraperitoneal inguinal hernia repairs are well documented, the development of pneumothorax, pneumomediastinum and subcutaneous emphysema is rarely reported. The authors' experience with a 23-year-old man who developed intraoperative bilateral pneumothoraces and cervical subcutaneous emphysema during a laparoscopic totally extraperitoneal inguinal hernia repair prompted a MEDLINE literature review. Seven similar cases were found in which the patients developed pneumothorax, pneumomediastinum and/or subcutaneous emphysema following laparoscopic hernioplasty. An intercostal catheter was inserted in two out of the seven patients only. Numerous hypotheses were proposed for the development of these complications. Several authors felt that the duration of the procedure and preperitoneal insufflation pressures are related to the development of these complications. These potentially lethal complications must be diagnosed and managed promptly.     

Thoracic trauma in the pre-hospital phase

Preclinically relevant injuries of the thorax are described patho-physiologically. The diagnosis at the scene of accident and the treatment of the emergency of the functional after-effect injury are described. Respiratory insufficiency requires early artificial respiration. A pneumothorax should be drained, at least, on the respired patient. If there is a pneumothorax associated with tension due to the confined air, the relief would be obligatory. The relief should take place after the digital opening of the thorax by silicon drainage. If there is a mediastinal emphysema with a seriously haemodynamic effect, the relief would be indicated by collar mediastinostomy. If there is a pericardium tamponade with circulatory collapse after a perforating trauma, the patient must be brought to the medical attention of a surgeon as quickly as possible. The delay in time must not be the consequence of the relief of puncture. If a person injured in an accident who has a rupture of the trachea can not be respired immediate exposure of the rupture site is imperative. Resuscitation measures in case of an injured thorax must be done at the opened thorax.     

Tension pneumothorax and subcutaneous emphysema during retrieval of an ingested lithium button battery

We present a case of a child with an ingested lithium battery causing esophageal perforation with mediastinal injury extending to the pleural cavity. During the endoscopic retrieval of the battery, the child developed the rare complication of subcutaneous emphysema, tension pneumothorax, and pneumomediastinum from excessive iatrogenic air insufflation. The patient developed mediastinitis and had a complicated postoperative course.     

Benignes subkutanes Emphysem nach Nagelpenetration

Crepitus under the skin after penetrating injuries: harmless benign subcutaneous emphysema or life-threatening infection with gas-producing bacteria (gas gangrene because of Clostridium perfringens, crepitating cellulitis because of anaerobic Streptococcus or other coliforme bacteria)? We report a case of a 74-year-old male who developed massive crepitation of the left upper extremity and the lateral thoracic wall and mediastinal emphysema after sustaining a laceration of the left thumb and forefinger from a nail. Because there was the suspicion of gas gangrene we performed generous skin incisions of the ventral and dorsal part of the hand, the forearm and upper arm and open wound treatment. A triple antibiotic therapy was initiated. Due to fast regression of the subcutaneous emphysema and the mediastinal emphysema, continuing lack of symptoms, negative smear test results from the beginning and low infection parameters in the blood all wounds could be closed 9 days after primary surgery. The suspicion of gas gangrene was not confirmed so the diagnosis of benign subcutaneous emphysema was made.     

Epidural emphysema associated with primary spontaneous pneumothorax.

A 21-year-old male patient was admitted with spontaneous pneumothorax, and no history of asthma. Closed drainage treatment was unsuccessful. Chest computed tomography demonstrated pneumomediastinum and subcutaneous emphysema with multiple air bubbles within the spinal canal between the levels Th3 and Th11. Resection of bullae on the upper lobe and partial pleurectomy were performed. Postoperative period was uneventful. Epidural emphysema was resolved spontaneously without neurologic symptoms and signs. Intraspinal air, or pneumorachis, associated with spontaneous pneumothorax and pneumomediastinum is an extremely rare condition. We discussed spontaneous pneumothorax and pneumomediastinum as well as epidural pneumatosis and reviewed reported cases in the literature.