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Subcutaneous Emphysema Is Not Always Benign: A Rare Case of Extrapleural Hematomas FREE TO VIEW

Daniel Gutteridge, MD; Damien Patel, MD; Casey Stahlheber, MD
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Indiana University School of Medicine, Indianapolis, IN

Chest. 2014;146(4_MeetingAbstracts):268A. doi:10.1378/chest.1983606
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SESSION TITLE: Critical Care Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: With increasing rates of prolonged mechanical ventilation, placement of tracheostomies has increased. While there are many advantages to long term ventilation through a tracheostomy, the procedure also comes with many possible complications. One common complication with of tracheostomy placement is subcutaneous emphysema (SE), which is typically benign and resolves within 48 hours. Rarely, SE can be massive and widespread, leading to complications of its own. In a few cases, of massive SE are has been reported to cause arterial dissections of the carotid and vertebral arteries. We report a rare, possibly never before reported, case of large, bilateral, extra-pleural hematomas due to intercostal artery dissections secondary to massive SE post tracheostomy.

CASE PRESENTATION: An 87-year-old Caucasian male presented to our institution in acute respiratory distress secondary to idiopathic bilateral vocal cord paralysis, requiring emergent tracheostomy placement in the operating room. He had no history of other invasive procedures in the chest or neck. Two days later he developed increasing dyspnea and massive SE. The tracheostomy site revealed a tracheal tear requiring correction. The subcutaneous air was treated conservatively. Subsequently, the patient had an unexplained drop in hemoglobin along with an abnormal chest X-ray, prompting a computed tomography of the chest. Large extra-pleural hematomas were noted bilaterally along the posterior lateral chest wall.

DISCUSSION: The frequency of SE immediately post tracheostomy placement is around 5%. It is considered a minor complication with typically benign consequences that resolves without intervention. Rarely, massive SE can result from thoracic and neck procedures and can lead to more serious complications like arterial dissection. Spontaneous arterial dissection from SE is thought to be the result of shearing forces created by blunt dissection of facial planes. Treatment strategies for SE are primarily supportive but in cases of massive SE attempts to place subcutaneous drains have found mixed results.

CONCLUSIONS: Percutaneous tracheostomies in critically ill patients are often a necessary step in long term ventilator weaning but do come with serious risks. This case highlights an undescribed and potentially life-threatening complication of SE that clinicians should be aware of in the care of a tracheostomy patient.

Reference #1: Parrillo J, Dellinger R. Critical Care Medicine: Principles of Diagnosis and Management in the Adult, 4th Edition. Elsevier, 2014.

DISCLOSURE: The following authors have nothing to disclose: Daniel Gutteridge, Damien Patel, Casey Stahlheber

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