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Table of Contents
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 71-73

Extensive subcutaneous emphysema masquerading as anaphylaxis

1 Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha, India
2 Department of Community Medicine and Family Medicine, AIIMS, Bhubaneswar, Odisha, India

Date of Submission24-Feb-2020
Date of Decision31-Mar-2020
Date of Acceptance29-Apr-2020
Date of Web Publication5-Jun-2020

Correspondence Address:
Upendra Hansda
Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCFM.IJCFM_18_20

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Road traffic accident is not uncommon in India. Though the chest injury is less common after road traffic accident it may present atypically. Delay in diagnosis of a life threatening chest injury may lead to death. We are reporting a case of extensive subcutaneous emphysema after road traffic accident. The subcutaneous emphysema was due to tension pneumothorax, which was managed in time to save the patient.

Keywords: Anaphylaxis, subcutaneous emphysema, tension pneumothorax

How to cite this article:
Hansda U, Giri PP, Sahoo S. Extensive subcutaneous emphysema masquerading as anaphylaxis. Indian J Community Fam Med 2020;6:71-3

How to cite this URL:
Hansda U, Giri PP, Sahoo S. Extensive subcutaneous emphysema masquerading as anaphylaxis. Indian J Community Fam Med [serial online] 2020 [cited 2021 Apr 18];6:71-3. Available from: https://www.ijcfm.org/text.asp?2020/6/1/71/286019

  Introduction Top

About 2.18 lakh people had died in India due to road traffic injury in 2017.[1] The extremities (53%) and maxillofacial (19%) injuries are the most common after road traffic accidents. Chest injuries are though less (4.6%)[2] chances of missing the diagnosis are high as they may present very differently. This is an atypical presentation of road traffic injury with extensive subcutaneous emphysema (SE) and tension pneumothorax (TP) the diagnosis of which was nearly missed in the emergency room (ER).

  Case Report Top

A 45-year-old male was brought to the ER with a history of road traffic accidents. On arrival, he was conscious and oriented. On examination, his heart rate was 100 beats/min, blood pressure was 130/82 mmHg with respiratory rate 40/min, and oxygen saturation 95%. As the patient was tachypneic, oxygen was supplemented immediately through a rebreathing oxygen mask. On inspection during quick clinical examination, extensive swelling all over the body was found [Figure 1].
Figure 1: Extensive subcutaneous emphysema extending up to the scrotum

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As the patient had difficulty in breathing and high respiratory rate, it was presumed to be anaphylaxis. On palpation, crepitus was there, which made the diagnosis of anaphylaxis less likely. About 10 min later, his respiratory rate was decreasing and he was unable to talk. Anticipating the respiratory arrest, the patient was being ventilated with a bag and mask. During bag and mask ventilation, there was no visible rise of the chest and no breath sound. As a history of trauma, breathing difficulty, and absent of breath sound after providing a few positive pressure ventilation with bag and mask, TP was suspected. Hence, needle decompression was attempted with a 16G over-the-needle catheter at the second intercostal space in the left midclavicular line (MCL), which was failed. Then, the chest tube was inserted at the left fifth intercostal space, just anterior to the midaxillary line. Endotracheal intubation was done, and positive pressure ventilation started. Immediately, the patient developed hemodynamic collapse and cardiac arrest. Cardiopulmonary resuscitation (CPR) was started. As there was no improvement, another chest tube was inserted into the right side immediately. After two cycles of CPR, the return of spontaneous circulation was achieved. SE was decreased gradually [Figure 2] over 10 min after insertion of the chest tube on both sides. Then, the patient was transferred to the intensive care unit.
Figure 2: Reduction of subcutaneous emphysema after chest tube insertion

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  Discussion Top

In TP, the air is trapped in pleural space without escape. It is a life-threatening condition. Clinical features are chest pain, air hunger, tachypnea, tachycardia, hypotension, contralateral deviation of the trachea, the absence of breath sound, hyper resonant on percussion, distended neck veins, and cyanosis. In our case, the patient had respiratory distress, there was no breath sound on auscultation and the neck veins were not visible due to massive SE. TP is only a clinical diagnosis, and the time should not be wasted for radiologic confirmation. Point of care ultrasound can be used for the confirmation of pneumothorax, which can be done within seconds,[3] but it is of no help in SE, because the air in subcutaneous space hampers the conduction of ultrasound waves. The recent evidence suggests for needle decompression at the fifth intercostal space just anterior to MCL.[4] Needle decompression may not be successful always. Hence, finger thoracostomy is an alternative. After needle decompression, chest tube thoracostomy is mandatory. Needle decompression is a simple life-saving procedure which can be performed by primary care physicians at peripheral hospitals also. Hence, the diagnosis of SE and TP is important.

The features of anaphylaxis are skin rash, swollen skin, runny nose, respiratory distress, swollen lips and tongue, hoarse voice, paleness, and shock but there is absence of subcutaneous crepitus. Earley et al. reported a case of SE after a history of fall presented with breathing difficulty.[5] Their patient had no external injury over the chest but had SE over the chest, abdomen, and upper abdomen. They started managing the patient as a case of anaphylaxis, and the patient expired. In autopsy, they found that there was no evidence of anaphylactic changes in the airways. Our patient had SE over the chest, abdomen, upper limb, and below up to scrotum. Hence, the finding of crepitus on clinical examination, ruled out the chances of anaphylaxis. Dhawan et al. reported a case presenting with gradual swelling of face and breathing difficulty in chronic obstructive pulmonary disease (COPD).[6] In their patient, the lips were spared from the swelling. In anaphylaxis, 60%–90% of cases swelling of the lips occurs. On detailed history, clinical examination and investigation, it was diagnosed as SE over the face. Trauma is the second most common cause of SE after COPD.[7] The extensive SE is due to broncho-subcutaneous fistula. We could able to manage our patient as per the advanced trauma life support protocol.

  Conclusion Top

History of injury, findings of external injuries, and crepitus on physical examination can give a clue to rule out anaphylaxis. Detection of crepitus during clinical examination indicates toward the diagnosis of pneumothorax and appropriate management can save a life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

India State-Level Disease Burden Initiative Road Injury Collaborators. Mortality due to road injuries in the states of India: The Global Burden of Disease Study 1990-2017. Lancet Public Health 2020;5:e86-98.  Back to cited text no. 1
Singh R, Singh HK, Gupta SC, Kumar Y. Pattern, severity and circumtances of injuries sustained in road traffic accidents: A tertiary care hospital-based study. Indian J Community Med 2014;39:30-4.  Back to cited text no. 2
[PUBMED]  [Full text]  
Chen L, Zhang Z. Bedside ultrasonography for diagnosis of pneumothorax. Quant Imaging Med Surg 2015;5:618-23.  Back to cited text no. 3
Stewart RM, Merrick C. Advanced Trauma Life Support Student Course Manual. 10th ed. Chicago: American College of Surgeons; 2018. p. 65-6.  Back to cited text no. 4
Earley A, Watkins T, Forde N. Massive subcutaneous emphysema mimicking anaphylaxis-pathological and radiological correlations. Forensic Sci Med Pathol 2019;15:603-6.  Back to cited text no. 5
Dhawan AK, Singal A, Bisherwal K, Pandhi D. Subcutaneous emphysema mimicking angioedema. Indian Dermatol Online J 2016;7:55-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
Aghajanzadeh M, Dehnadi A, Ebrahimi H, Fallah Karkan M, Khajeh Jahromi S, Amir Maafi A, et al. Classification and management of subcutaneous emphysema: A 10-year experience. Indian J Surg 2015;77:673-7.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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