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| {{Subcutaneous emphysema}} | | {{Subcutaneous emphysema}} |
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| {{CMG}} | | {{CMG}} |
| ==Causes== | | ==Overview== |
| ===Trauma===
| | Subcutaneous emphysema can result from puncture of parts of the [[respiratory system|respiratory]] or [[gastrointestinal system]]s. Particularly in the [[thorax|chest]] and neck, air may become trapped as a result of [[penetrating trauma]] (e.g., [[gunshot wound]]s or stab wounds) or [[blunt trauma]]. [[Infection]] (e.g., [[gas gangrene]]) can cause gas to be trapped in the subcutaneous tissues. Subcutaneous emphysema can be caused by medical procedures and medical conditions that cause the pressure in the [[alveoli]] of the lung to be higher than that in the tissues outside of them.<ref name="Maunder84"> |
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| [[Image:Pulmonary contusion.jpg|thumb|left|A chest X-ray of a right sided [[pulmonary contusion]] associated with [[flail chest]] and subcutaneous emphysema]] | |
| Conditions that cause subcutaneous emphysema may result from both blunt and penetrating trauma;<ref name="Parker90">
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| {{ | | {{ |
| cite journal |author=Parker GS, Mosborg DA, Foley RW, Stiernberg CM |title=Spontaneous cervical and mediastinal emphysema |journal=Laryngoscope |volume=100 |issue=9 |pages=938–940 |year=1990 |month=September |pmid=2395401 |doi= |url= | | cite journal |author=Maunder RJ, Pierson DJ, Hudson LD |title=Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management |journal=Arch. Intern. Med. |volume=144 |issue=7 |pages=1447–53 |year=1984 |month=July |pmid=6375617 |doi= |url= |
| }} | | }} |
| </ref> SCE is often the result of a stabbing or gunshot wound.<ref name="Peart06"> | | </ref> Its most common causes are [[pneumothorax]] and an improperly functioning [[chest tube]]. It can also occur spontaneously due to rupture of the alveoli, with dramatic signs.<ref name="Parker90"> |
| {{ | | {{ |
| cite journal |author=Peart O |title=Subcutaneous emphysema |journal=Radiologic Technology |volume=77 |issue=4 |pages=296 |year=2006 |pmid=16543482 |doi= |url= | | cite journal |author=Parker GS, Mosborg DA, Foley RW, Stiernberg CM |title=Spontaneous cervical and mediastinal emphysema |journal=Laryngoscope |volume=100 |issue=9 |pages=938–940 |year=1990 |month=September |pmid=2395401 |doi= |url= |
| }} | | }} |
| </ref> | | </ref> When the condition is caused by surgery it is called surgical emphysema.<ref> |
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| [[Chest trauma]], a major cause of subcutaneous emphysema, can cause air to enter the skin of the chest wall from the neck or lung.<ref name="Brown04">
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| {{ | | {{ |
| cite book |author=DeGowin RL, LeBlond RF, Brown DR |title=DeGowin's Diagnostic Examination |publisher=McGraw-Hill Medical Pub. Division |location=New York |year=2004 |pages= 388, 552 |isbn=0-07-140923-8 |oclc= |doi= |accessdate= 2008-05-12 |url= http://books.google.com/books?id=6KUprj41xNIC&pg=PA552&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=QVoEhl9tFLvxIdakFZmEwoHD-94 | | cite book |author=|title=Oxford Concise Medical Dictionary |publisher=Oxford University Press |location=Oxford, UK |edition=6th |year=2003 |isbn=0-19-860753-9 |oclc= |doi= |accessdate= |
| }} | | }} |
| </ref> When the [[pleura]]l membranes are punctured, as occurs in penetrating trauma of the chest, air may travel from the lung to the muscles and subcutaneous tissue of the chest wall.<ref name="Brown04"/> When the alveoli of the lung are ruptured, as occurs in [[pulmonary laceration]], air may travel beneath the [[visceral pleura]] (the membrane lining the lung), to the [[Hilum of lung|hilum of the lung]], up to the [[trachea]], to the neck and then to the chest wall.<ref name="Brown04"/> The condition may also occur when a [[rib fracture|fractured rib]] punctures a lung;<ref name="Brown04"/> in fact, 27% of patients who have rib fractures also have subcutaneous emphysema.<ref name="Schnyder00"> | | </ref> The term spontaneous subcutaneous emphysema is used when the cause is not clear.<ref name="Parker90"/> |
| | Subcutaneous emphysema is not usually serious in and of itself, but the underlying causes, such as pneumothorax, can be.<ref name="Brooks98"> |
| {{ | | {{ |
| cite book |author=Schnyder P, Wintermark M |title=Radiology of Blunt Trauma of the Chest |publisher=Springer |location=Berlin |year=2000 |pages=10–11 |isbn=3-540-66217-0 |oclc= |doi= |accessdate= 2008-05-06 |url = http://books.google.com/books?id=Q4haCU0cX14C&pg=PA10&dq=subcutaneous+emphysema&lr=&sig=C7DbMJOQmB-m1YgW6qchCU4bDl0 | | cite book |author=Brooks DR |title=Current Review of Minimally Invasive Surgery |publisher=Current Medicine |location=Philadelphia |year=1998 |pages=36 |isbn=0-387-98338-4 |oclc= |doi= |accessdate= |
| }}
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| </ref> Rib fractures may tear the [[parietal pleura]], the membrane lining the inside of chest wall, allowing air to escape into the subcutaneous tissues.<ref name="Wicky00">
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| {{
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| cite journal |author=Wicky S, Wintermark M, Schnyder P, Capasso P, Denys A |title=Imaging of blunt chest trauma |journal=European Radiology |volume=10 |issue=10 |pages=1524–1538 |year=2000 |pmid=11044920 |doi= |url=
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| }} | | }} |
| </ref> | | </ref> |
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| Subcutaneous emphysema is a frequently found in pneumothorax (air outside of the lung in the chest cavity)<ref name="Hwang96">
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| {{
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| cite journal |author= Hwang JCF, Hanowell LH, Grande CM |title=Peri-operative concerns in thoracic trauma |journal= Baillière's Clinical Anaesthesiology |volume = 10 |issue = 1 |page=123–153 |doi= doi:10.1016/S0950-3501(96)80009-2 | date=1996
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| }}<!--No PMID found-->
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| </ref><ref name="Myers02">
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| {{
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| cite book |author=Myers JW, Neighbors M, Tannehill-Jones R |title=Principles of Pathophysiology and Emergency Medical Care |publisher=Delmar Thomson Learning |location=Albany, N.Y |year=2002 |pages=121 |isbn=0-7668-2548-5 |oclc= |doi= |accessdate=2008-06-16 |url = http://books.google.com/books?id=GgDdMkAZNPkC&pg=PA121&dq=%22sternal+fracture%22&lr=&client=firefox-a&sig=C7epwySocqqYZ5GNIG2en4knPrE
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| }}
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| </ref> and may also result from [[pneumomediastinum|air in the mediastinum]], [[pneumopericardium]] (air in the [[pericardial cavity]] around the heart).<ref name="Bonnett04">
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| {{
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| cite book |author=Grathwohl KW, Miller S |chapter= Anesthetic implications of minimally invasive urological surgery |editor= Bonnett R, Moore RG, Bishoff JT, Loenig S, Docimo SG |title=Minimally Invasive Urological Surgery |publisher=Taylor & Francis Group |location=London |year=2004 |pages= 105 |isbn=1-84184-170-6 |oclc= |doi= |accessdate=2008-05-11 |url= http://books.google.com/books?id=nU5WGRBeBBQC&pg=PA105&dq=subcutaneous+emphysema&client=firefox-a&sig=wajVVMwrwxWexK7G2DZYshGDxOU
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| }}
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| </ref> A [[tension pneumothorax]], in which air builds up in the [[pleural cavity]] and exerts pressure on the organs within the chest, makes it more likely that air will enter the subcutaneous tissues through pleura torn by a broken rib.<ref name="Wicky00"/> When subcutaneous emphysema results from pneumothorax, air may enter tissues including those of the face, neck, chest, armpits, or [[abdomen]].<ref name="pleural">
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| {{
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| cite book |editor=Bouros D |title=Pleural Disease (Lung Biology in Health and Disease) |publisher=Marcel Dekker |location=New York, N.Y |year=2004 |isbn=0-8247-4027-0 |oclc= |doi= |accessdate= 2008-05-16 |chapter=Pleural disease in the intensive care unit |author=Papiris SA, Roussos C |pages=771–777|url= http://books.google.com/books?id=PS8j3r31vWwC&pg=PA771&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=V8fQvguiH5tb-2xS6Sf8UnQGiGQ }}
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| </ref>
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| [[Image:Pneumothorax CT.jpg|left|thumb|A CT scan of a pneumothorax, one of the most common causes of subcutaneous emphysema]]
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| When subcutaneous emphysema occurs with pneumomediastinum, the condition is known as [[Hamman's syndrome]].<ref name="Jain08"/> Pneumomediastinum can result from a number of events. For example, foreign body [[Pulmonary aspiration|aspiration]], in which someone inhales an object, can cause pneumomediastinum (and lead to subcutaneous emphysema) by puncturing the airways or by increasing the pressure in the affected lung(s) enough to cause them to burst.<ref name="Findlay03">
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| {{
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| cite journal |author=Findlay CA, Morrissey S, Paton JY |title=Subcutaneous emphysema secondary to foreign-body aspiration |journal=Pediatric Pulmonology |volume=36 |issue=1 |pages=81–82 |year=2003 |month=July |pmid=12772230 |doi=10.1002/ppul.10295 |url=
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| }}
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| </ref>
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| Subcutaneous emphysema of the chest wall is commonly among the first signs to appear that [[barotrauma]], damage caused by excessive pressure, has occurred,<ref name="pleural"/><ref name="Criner02">
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| {{
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| cite book |author=Criner GJ, D'Alonzo GE |title=Critical Care Study Guide: text and review |publisher=Springer |location=Berlin |year=2002 |pages= 169 |isbn=0-387-95164-4 |oclc= |doi= |accessdate=2008-05-12 |url= http://books.google.com/books?id=pcHuRboVuXUC&pg=PA169&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=fy7fEDoBw3gz1C5JcvQ6o1ANzxY#PPA169,M1
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| }}
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| </ref> and it is an indication that the lung was subjected to significant barotrauma.<ref name="Rankine00">
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| {{
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| cite journal |author=Rankine JJ, Thomas AN, Fluechter D |title=Diagnosis of pneumothorax in critically ill adults |journal=Postgraduate Medical Journal |volume=76 |issue=897 |pages=399–404 |year=2000 |month=July |pmid=10878196 |doi= |url=http://pmj.bmjjournals.com/cgi/pmidlookup?view=long&pmid=10878196
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| }}
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| </ref> Thus the phenomenon may occur in diving injuries.<ref name="Parker90"/>
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|
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| Trauma to parts of the respiratory system other than the lungs, such as rupture of a [[bronchial tube]], may also cause subcutaneous emphysema.<ref name="Wicky00"/> Air may travel upward to the neck from a pneumomediastinum that results from a bronchial rupture, or downward from a torn trachea or [[larynx]] into the soft tissues of the chest.<ref name="Wicky00"/> It may also occur with [[bone fracture|fractures]] of the [[facial bone]]s, [[neoplasm]]s, during [[asthma]] attacks, when the [[Heimlich maneuver]] is used, and during [[childbirth]].<ref name="Parker90"/> It is estimated to occur with pneumomediastinum in one in every 2000–100,000 deliveries.<ref name="Jain08">
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| {{
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| cite journal |author=Jain P, Vanner T |title=Subcutaneous emphysema with pneumomediastinum during the second stage of labour: A rare intrapartum complication |journal=The Internet Journal of Gynecology and Obstetrics |volume=9 |issue=1 |pages= |year=2008 |pmid= |doi= |url=http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijgo/vol9n1/emphysema.xml
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| }}
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| </ref> Injury with [[pneumatic tool]]s, those that are driven by air, is also known to cause subcutaneous emphysema, even in extremities (the arms and legs).<ref name="Molen99">{{cite journal |author=van der Molen AB, Birndorf M, Dzwierzynski WW, Sanger JR |title=Subcutaneous tissue emphysema of the hand secondary to noninfectious etiology: a report of two cases |journal=J Hand Surg [Am] |volume=24 |issue=3 |pages=638–41 |year=1999 |month=May |pmid=10357548 |doi= |url=}}</ref> It can also occur as a result of rupture of the [[esophagus]]; when it does, it is usually as a late sign.<ref name="pleural2">
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| {{
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| cite book |editor=Bouros D |title=Pleural Disease (Lung Biology in Health and Disease) |publisher=Marcel Dekker |location=New York, N.Y |year=2004 |isbn=0-8247-4027-0 |oclc= |doi= |accessdate= 2008-05-16 |chapter=Pleural disease in the intensive care unit| chapter=Pleural effusions in gastrointestinal tract diseases| author= Kosmas EN, Polychronopoulos VS |pages=798| url=
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| http://books.google.com/books?id=PS8j3r31vWwC&pg=PA771&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=V8fQvguiH5tb-2xS6Sf8UnQGiGQ
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| }}
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| </ref>
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| ===Medical Treatment===
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| Subcutaneous emphysema is a common result of certain types of surgery; for example it is not unusual in [[thoracic surgery|chest surgery]].<ref name="Long95">
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| {{
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| cite book |author=Long BC Cassmeyer V, Phipps WJ|title=Adult Nursing: Nursing Process Approach |publisher=Mosby |location=St. Louis |year=1995 |pages=328 |isbn=0-7234-2004-1 |oclc= |doi= |accessdate= 2008-05-12 |url= http://books.google.com/books?id=7g9NirASUQsC&pg=PA328&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=heyGKZpNbSff_ybdIIN8KqTbC6s#PPA328,M1
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| }}
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| </ref> It may also occur from surgery around the esophagus, and is particularly likely in prolonged surgery.<ref name="Brooks98">
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| {{
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| cite book |author=Brooks DR |title=Current Review of Minimally Invasive Surgery |publisher=Current Medicine |location=Philadelphia |year=1998 |pages=36 |isbn=0-387-98338-4 |oclc= |doi= |accessdate=
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| }}
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| </ref> Other potential causes are [[anesthesia]], in which its occurrence is frequently unexpected,<ref name="Pan89">
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| {{
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| cite journal |author=Pan PH |title=Perioperative subcutaneous emphysema: Review of differential diagnosis, complications, management, and anesthetic implications |journal=Journal of Clinical Anesthesia |volume=1 |issue=6 |pages=457–459 |year=1989 |pmid=2696508 |doi= |url=
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| }}
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| </ref> [[laparoscopy]],<ref name="Brooks98"/> and [[cricothyrotomy]]. In a [[pneumonectomy]], in which an entire lung is removed, the remaining bronchial stump may leak air, a rare but very serious condition that leads to progressive subcutaneous emphysema.<ref name="Long95"/> Air can leak out of the pleural space through an incision made for a [[thoracotomy]] to cause subcutaneous emphysema.<ref name="Long95"/> On infrequent occasions, the condition can result from [[dental]] surgery, usually due to use of high-speed tools that are air driven.<ref name="Monsour89">
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| {{
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| cite journal |author=Monsour PA, Savage NW |title=Cervicofacial emphysema following dental procedures |journal=Australian Dental Journal |volume=34 |issue=5 |pages=403–406 |year=1989 |month=October |pmid=2684113 |doi= |url=
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| }}
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| </ref> These cases result in usually painless swelling of the face and neck, with an immediate onset, the [[crepitus]] (crunching sound) typical of subcutaneous emphysema, and often with subcutaneous air visible on X-ray.<ref name="Monsour89"/>
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| One of the main causes of subcutaneous emphysema, along with pneumothorax, is an improperly functioning chest tube.<ref name="Lefor02">
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| {{
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| cite book |author=Lefor, Alan T. |title=Critical Care on Call |publisher=Lange Medical Books/McGraw-Hill, Medical Publishing Division |location=New York |year=2002 |pages= |isbn=0-07-137345-4 |oclc= |doi= |accessdate=2008-05-09| pages=238–240 | url= http://books.google.com/books?id=6pvRaVggws8C&pg=PA238&dq=subcutaneous+emphysema&sig=nvI2yrrJ2DklEEyepNTk7euYVq4
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| </ref> Thus subcutaneous emphysema is often a sign that something is wrong with a chest tube; it may be clogged, clamped, or out of place.<ref name="Lefor02"/> The tube may need to be replaced, or, when large amounts of air are leaking, a new tube may be added.<ref name="Lefor02"/>
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| Since [[mechanical ventilation]] can worsen a pneumothorax, it can force air into the tissues; when subcutaneous emphysema occurs in a ventilated patient, it is an indication that the ventilation may have caused a pneumothorax.<ref name="Lefor02"/> It is not unusual for subcutaneous emphysema to result from [[positive pressure ventilation]].<ref name="Conetta93">
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| {{
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| cite journal |author=Conetta R, Barman AA, Iakovou C, Masakayan RJ |title=Acute ventilatory failure from massive subcutaneous emphysema |journal=Chest |volume=104 |issue=3 |pages=978–980 |year=1993 |month=September |pmid=8365332 |doi= |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=8365332
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| }}</ref>
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| Another possible cause is a ruptured trachea.<ref name="Lefor02"/> The trachea may be injured by [[tracheostomy]] or [[intubation|endotracheal intubation]]; in cases of tracheal injury, large amounts of air can enter the subcutaneous space.<ref name="Lefor02"/> An [[endotracheal tube]] can puncture the trachea or bronchi and cause subcutaneous emphysema.<ref name="Peart06"/>
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| ===Infection===
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| Air can be trapped under the skin in [[necrotizing]] infections such as [[gangrene]], occurring as a late sign in gas gangrene,<ref name="Lefor02"/> of which it is the [[hallmark]] sign. Subcutaneous emphysema is also considered a hallmark of [[fournier gangrene]].<ref name="Levenson08">
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| {{
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| cite journal |author=Levenson RB, Singh AK, Novelline RA |title=Fournier gangrene: Role of imaging |journal=Radiographics |volume=28 |issue=2 |pages=519–528 |year=2008 |pmid=18349455 |doi=10.1148/rg.282075048 |url=
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| </ref> Symptoms of subcutaneous emphysema can result when infectious organisms produce gas by [[fermentation]]. When emphysema occurs due to infection, signs that the [[infection]] is systemic, i.e. that it has spread beyond the initial location, are also present.<ref name="Brown04"/><ref name="Molen99"/>
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| ==References== | | ==References== |
| {{reflist|2}} | | {{reflist|2}} |
| {{WH}}
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| {{WS}}
| | [[Category:Needs causes]] |
| [[Category:Needs content]] | |
| [[Category:Disease]]
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| [[Category:Chest trauma]] | | [[Category:Chest trauma]] |
| [[Category:Pulmonology]] | | [[Category:Pulmonology]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| | [[Category:Physical examination]] |
| | [[Category:Needs content]] |
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| | {{WH}} |
| | {{WS}} |