Dilemma in some cases of Surgical emphysema

•Many times such a situation is confronted in accident and emergency department .

PECULIAR SITUATION

• Sometime there is a situation where there is significant traumatic surgical emphysema with no clinical S/S of pneumothorax or haemo -thorax or rib fracture.

DILEMMA IS

• . Dilemma is what is the cause of this surgical emphysema where X ray chest and USG of chest findings are also equivocal.

MEDICOLEGAL ASPECT

• From medico legal point of view also it is necessary to find out the cause(when pt. complain of assault) and also from further treatment point of view .

CASE -1 IN LITERATURE

• By going through the literature , an article speaks about 2 cases of this nature. Case No1 : Here there was no rib fracture , pneumothorax or haemo thorax on Ches X ray. CT Scan revealed pneumo mediastinum.

CASE NO -2

• Case No 2: This patient had similar findings and the other party complained that the treating doctor has injected air in subcutaneous plane to make injury to be dangerous in nature

• Referance: IIJFMT 4(1) 2006

CASE NO-3

• Diffuse subcutaneous emphysema, pneumomediastinum, and pneumothorax after dental extraction.

• Ann Emerg Med. 1993 Feb;22(2):248-50.• We present a case of subcutaneous

emphysema, pneumomediastinum, pneumothorax, and pneumoretroperitoneum after a dental procedure with an air-and-water-cooled turbine burr drill.

CASE --3

NEEDS MORE EXPERIMENTATION

• Ultimately experts opined that injury was traumatic and not iatrogenic. But in cadaver , surgical emphysema could be produced by injecting air with syringe. But it was observed that in living human beings this is to be experimented further.

HOW TO TACKLE?

• The situation can be handled by taking following points in to consideration:

• 1. We should be careful in such cases. Look for any needle puncture point on chest wall.

CONTINUED----

• 2. If X ray chest is normal, CT Scan may be helpful. If CT is inconclusive then MRI may be got done to locate pneumo mediastinum. Both are inconclusive then abdominal cavity may be attended.

• 3. Intercostal tube for drainage should be used for treatment selectively only if respiratory distress is there.• 4. Multiple incisions in skin

over chest may relieve the symptoms.

•THANKS