This patient was presented to us with severe life threatening conditions. We treated him at ICU, Rangpur Medical College Hospital and he was completely cured. Later a case presentation was done at Seminar Room of the same institute.

1. BLUNT CHEST TRAUMA

2. Blunt Chest Trauma followed by
Subcutaneous Emphysema- A
Case Report
Presenter:
Dr. Hriday Ranjan Roy, Asst. Prof. (Surgery)
Moderator: Assoc. Prof. Dr. B. D. Bidhu
Asst. Prof. Dr. Hamidul Islam
Organized by- Dept of ICU and
Dept of Surgery
Rangpur Medical College, Rangpur

3. Rasel, a young man aged 30 years hailing
from Hazipara, Thakugaon admitted into
RpMCH on 27/11/2013 at 11.45 PM in
Neurosurgery Dept with the history of RTA
(Motorcycle accident) 11 hours back. On
admission, he was severely dyspneic,
disoriented and huge swelling of his upper
chest, neck and face. No sign of any head
injury noted.

4. So on next morning (28/11/2013 at 10.15
AM) he was referred to MSU-IV. On next
day (29/11/2013) at 5.30 PM he was
transferred to ICU for life support
management as his conditions were
deteriorating severely.
The patient had history of drug addiction.

5. Physical examination in ICU
revealedSevere Respiratory distress (SOB),
Peripheral cyanosis,
Pulse- >140/min,
B.P- 150/100 mm of Hg,
Huge surgical emphysema of upper part of
chest, neck and face,
Crepitus (#rib) on right lateral chest wall on
palpation,

6. Physical examination in ICU
revealed (cont.)
Pulse oxymeter- saturation <80%,
GCS was 14.
P/A- normal,
Limbs- Normal,
Whole body sorting- A 2 inch cut injury on scalp,
otherwise no injury found.
100% oxygen support given. But saturation was
not maintaining. Patient gradually became more
dyspneic and disoriented.

7. Photograph of patient
(27/11/2013)

8. Photograph of patient (02/12/2013)

9. CXR on 29/11/2013

10. Findings of CXR….
Huge surgical emphysema,
Equivocal finding of rib fracture,
Tension pneumothorax- suspected huge but
equivocal radiologically,
No hemothorax noted.

11. Management given
Urgent chest drainage (Rt) (water seal)
O2 inhalation- 100%
Antibiotics
Analgesics
I/V fluids,
PPIs

12. Proper technique of IT drainage
Site- 6th or 7th ICS just behind anterior axillary
line. In female, just below infra-mammary
line.
Anchoring sutureEncircling suture- (matress) to include
muscle, fascia of thoracic wall to avoid IT
complications.
How much marking of chest drain tube?
Know the proper way to avoid
complications

13. Landmarks for male

14. Landmark for female

15. What happened?
Patient was feeling a sort of pain and
saturation fall below 85% immediately
after tube thoracostomy. An extra dose of
analgesic given (Inj- Anadol).
Within 1 hour, patient began to improve.

16. Signs of improvement (within 1 hour)
Work of breathing (dyspnea)- reduced
gradually,
O2 saturation- raised over 90% and become
stable,
O2 flow and percent reduced and it
maintained the saturation.
Patient began to fell better.

17. On next day (30/11/2013)
Patient’s condition was fluctuating,
All of his parameters were improving.
But his O2 saturation was fluctuating
between 85-90% on 1st 2/3 days. Close
monitoring done with all sorts of
equipments.

18. Post-operative events (cont..)
Except O2 saturation, all other parameters
were stable and improving. So
Endotracheal Intubation was avoided.
Patient became stable gradually on 3 rd POD
onwards.

19. Another CXR was done on
04/12/2013

20. Findings of CXR
No pneumothorax,
No hemothotax
Surgical emphysema- minimal.
So, chest drain was removed on 04/12/201.

21. Comparison of pre and post IT CXR

22. Photograph of patient taken on
04/12/2013

23. Comparison of Photograph
(Pre and Post Treatment)

24. Smiling family photo….

25. They are smiling….
Their smile is
valued Trillion
Dollars to us.

26. ICU personnel involved in
management

27. Our (ICU) expressions…
We (ICU Staffs) are very much happy,
There were 3 or more similar cases
(Trauma) which were managed similarly
and results were excellent.
We would like to improve and spread our
experiences and thus to serve for
humanity.

28. DISCUSSION (Cont..)
Standard protocol of trauma managementATLS protocol (Ref- Baily and Love)
• Protocol of surgical emphysema after
chest trauma – “Tube Thoracostomy”
(Ref- Porhomayon and Doerr International Journal of
Emergency Medicine 2011, 4:10
http://www.intjem.com/content/4/1/10)

29. Management of Blunt trauma
90% of chest trauma managed by- IT drainage,
O2 inhalation, Physiotherapy, Analgesics,
Antibiotics and Desiccation therapy.
10% may need Thoracotomy. Indications are>1500ml blood at initial IT;
Continuous brisk bleeding >100ml/h for >1h;
Continued bleeding >200ml/h for >3h;
Rupture of bronchus, esophagus, aorta or
diaphragm;
Cardiac temponade.

30. DISCUSSION (Cont…)
Mechanism of
Surgical
emphysema
after chest
trauma-

31. Pneumothoarax

32. DISCUSSION (Cont…)
How surgical
emphysema
corrected by chest
drain?
Air of emphysema has
direct communication
with air of
pneumothorax.

33. DISCUSSION (Cont…)
Multiple stab or wide bore needle aspirationhave any value for emphysema?
It may delay improvement due to
entrance of atmospheric air into pleural
space.
What other protocols?

34. DISCUSSION (Cont…)
Chest strapping after rib fracture? NO
Disadvantages- Restrict movement of that
part of chest. Result- reduced ventilation,
increase prone to infection and thus
detrimental.
Modern concepts- If no pain, cont. lung
injury- nothing to do except drain.

35. Discussion (Cont..)
Indications of Tube
Thoracostomy in General
About 90% of thoracic surgical cases could
be managed by Tube Thoracostomy.
Indications are: (described earlier)

36. CONCLUSION
The value of Human life is above all. All
doctors are ethically bound for that.
Ego should not be practiced here or old
concepts (which may be detrimental for
patient) should not be applied.
IT drainage has no loss, but valued
many. Please don’t hesitate to insert a
chest drainage in such patients.

37. THANK YOU