Buried in Trapped Air: Tension Pneumothorax, Massive Subcutaneous Emphysema and the Battle for Airway Control

Abstract

ABSTRACT:  Background: Tension pneumothorax (TP) is defined as a pneumothorax in which the pressure of intrapleural air exceeds atmospheric pressure, producing adverse effects, including contralateral mediastinal shift associated with cardiovascular collapse, due to reduced venous return (because of compression of the SVC and IVC ) and hypoxia.   Usually, patients with TP present to the Emergency Department with vague pleuritic chest pain and shortness of breath, but being considered a red flag it should be diagnosed during the primary assessment and managed promptly with large bore needle decompression followed by chest tube insertion. Presence of extensive subcutaneous emphysema (SCE) can further aggravate the respiratory distress and make the airway management even more challenging in the ER. Situation can become even worse when such a patient needs cardiopulmonary resuscitation on arrival.Case report: We report an unusual case of a 55 years old man, who presented in the ER with history of sudden onset respiratory distress while taking bath. Patient was brought to the ER in a  state of gasping, hypoxia and shock . Needle decompression of the pneumothoraces was not sufficient as he also had extensive subcutaneous emphysema which resulted in cardiac arrest. The CPR and the airway management extremely were practically difficult. He was finally tracheostomised in the ER and accompanied by bilateral chest-tube thoracotomy. He was discharged for home after pleurodesis without any neurological deficit.Conclusion: Primary spontaneous pneumothorax is an uncommon condition but can rarely end up in tension pneumothorax and accompanying subcutaneous emphysema can make the management further challenging. Airway skills of the ER team are important in saving such patients’ lives.