Case Report: Tension Pneumothorax Complicated by Massive Subcutaneous Emphysema

Background: Tension pneumothorax is a condition with frequent fatal complications. This condition is caused by a disruption in the lung - that creates a one-way valve allowing air to accumulate in the pleural space. The fatal complication is the prevention of blood returning to the right side of the heart - due intrathoracic pressure compressing the right atrium. The patient can exhibit symptoms of dyspnea, tachypnea, tracheal deviation, jugular venous distention, subcutaneous emphysema, and shock that can lead to rapid deterioration and death.Case Report: We report a case of massive subcutaneous emphysema complicating tension pneumothorax management. The patient is a 20-year-old male who presented to the emergency department with chest trauma and was in extremis with diffuse severe subcutaneous emphysema. Due to the distorted anatomy, airway management and chest decompression were performed with nonstandard techniques/equipment resulting in rapid patient stabilization. After 4 days in the hospital, he was discharged home with no deficits.Discussion: Many providers do not have the proper equipment or training to treat patients in this extreme condition. CT images demonstrate the anatomical distortions in this case and the increase in size required for invasive life-saving devices. Images demonstrate where many commercial 14 gauge angiocaths and cricothyrotomy kits will not suffice (due to distortion in the anatomy), and these should not be relied on solely.Conclusions: While trauma carts frequently maintain (1.75 - 2 inch) 14 gauge angiocaths, they should also have military grade angiocaths that are 3.25” in length, which will work in most cases. Some, but not all, military-grade cricothyrotomy kits, or individually assembled kits, have 6.0 endotracheal tubes and come with a bougie and cricothyrotomy hook which would have been sufficient in this patient. Prehospital and hospital healthcare personnel should be prepared for similar patient encounters.