Delayed Tension Symptomatic Pneumoperitoneum After POEM Requiring Needle Decompression.

INTRODUCTION: Per-oral endoscopic myotomy (POEM) is an effective modality for the management of achalasia. Tension pneumoperitoneum is a significant complication that causes hemodynamic instability, generally within the periprocedural period. METHODS: Here, we report 2 cases of delayed tension pneumoperitoneum that was recognized and treated several hours after uncomplicated POEM. RESULTS: These cases illustrate the importance of continued vigilance for this complication outside of the immediate periprocedural period as well as the utility of computed tomography-guided aspiration in managing it. DISCUSSION: When discharging patients after POEM, caregivers should be aware of this rare complication and alert patients to return for immediate care when it happens.

Snap, crackle and pop: when sneezing leads to crackling in the neck.

Spontaneous perforation of the pharynx is an unusual condition. Due to its non-specific presentation and general lack of awareness, diagnosis and intervention may be delayed resulting in potential complications. This case reports a rare spontaneous perforation of the pyriform sinus after a forceful sneeze, leading to cervical subcutaneous emphysema and pneumomediastinum.

Case of chest pain in a young man.

A young man with a history of smoking presented with acute-onset chest pain after lifting weights. He also noticed a change in his voice, tightness in his neck and difficulty breathing. A chest radiograph showed soft tissue emphysema in the neck. A CT scan of the chest revealed moderate amount of pneumomediastinum tracking into the neck and down to the diaphragm. He was haemodynamically stable and had no hypoxia or dysphagia. He was monitored for 48 hours and discharged home after resolution of his symptoms. A chest radiograph repeated after 6 weeks was normal.

Oxygen embolism caused by accidental subcutaneous injection of hydrogen peroxide during orthopedic surgery: A case report.

INTRODUCTION: We report a 39-year-old male patient with a fracture of the right acetabulum undergoing open reduction and internal fixation with a plate under general anesthesia. At closure, the surgeons injected 0.75% ropivacaine into the subcutaneous tissue of the incision wound for postoperative analgesia. Soon after injection, subcutaneous emphysema at the injection site and a sudden decrease in end-tidal CO2 tension with crude oscillatory ripples during the alveolar plateau phase were observed. Shortly thereafter, it was found that the surgeons had mistakenly injected hydrogen peroxide instead of ropivacaine. Fortunately, the patient recovered to normal status after 10 minutes. After the surgery, the patient was carefully observed for suspected pulmonary embolism and discharged without complications. CONCLUSION: Adverse events related to medication errors can occur in operating rooms, and most cases can be prevented through communication and verification by medical staff. The use of hydrogen peroxide should be reevaluated; when used, medical staff should be aware of the risk of oxygen embolism and take extreme care.

Air and its Sonographic Appearance: Understanding the Artifacts.

BACKGROUND: Although air has traditionally been considered a barrier to sonographic imaging, when encountered in unusual settings it can serve as an important indicator of various pathologic states as well. Clinician recognition and thorough understanding of the characteristic pattern of artifacts generated by air are critical for making a number of important diagnoses. CASE SERIES: We present five emergency department cases in which air was visualized in a pathologic location. Pneumothorax, pneumoperitoneum, necrotizing fasciitis, or Fournier's gangrene, and subcutaneous emphysema and pneumomediastinum, can be rapidly and easily identified on ultrasound by the presence of air artifacts. The relevant sonographic findings are described and discussed in this article. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to its inherent impedance mismatch with other human tissues, air has a characteristic appearance on ultrasound that includes irregular hyperechoic structures, "dirty shadowing," A-lines, and decreased visualization of deeper structures. Knowledge of the sonographic appearance of air artifacts can assist the physician in making a diagnosis, selecting appropriate additional imaging, and enlisting specialist consultation.

Don't Blow It! Extensive Subcutaneous Emphysema of the Neck Caused by Isolated Facial Injuries: A Case Report and Review of the Literature.

BACKGROUND: Although subcutaneous emphysema resulting from maxillofacial surgery is well described in the literature, the association with maxillofacial trauma is less firm. Clinically evident subcutaneous emphysema from facial injury is uncommon and extension into the cervical and mediastinal tissues is exceedingly rare, with few reported cases. CASE REPORT: An unusual case of extensive subcutaneous emphysema after facial trauma is presented. The case posed a diagnostic dilemma in our emergency department. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Facial fractures are a rare but important cause of surgical emphysema. Emergency physicians need to be aware of the diagnostic possibility and the need to avoid factors that may precipitate secondary injury.

[Blunt chest trauma with pneumomediastinum and pneumoperitoneum secondary to Macklin effect. Case report]. / Trauma contuso de tórax con neumomediastino y neumoperitoneo secundario a efecto Macklin. Reporte de un caso.

BACKGROUND: Pneumomediastinum is the presence of free air around mediastinal structures, which may be spontaneous or secondary, and can occur in 10% of patients with blunt chest trauma, with the Macklin effect being its main pathophysiology. CLINICAL CASE: A 21 year old male, hit by motor vehicle, with alvéolopalatal fracture and blunt chest trauma, who, 72 hrs after admission, shows subcutaneous emphysema in the anterior chest. A simple tomography of the chest and abdomen was performed, finding a pneumomediastinum, bilateral pulmonary contusions and pneumoperitoneum. Oesophageal, tracheobronchial or intra-abdominal viscera injuries were ruled out, establishing the cause of pneumomediastinum and pneumoperitoneum due to the Macklin effect. This required conservative management in intensive care unit, with a favourable clinical course and discharged after a 10 day hospital stay. DISCUSSION: Macklin effect is caused by dissection of air medially along the bronchoalveolar sheath (interstitial emphysema), secondary to alveolar breakdown and extending into mediastinal and other anatomical structures (pneumoperitoneum). It has been documented in blunt trauma, as well as in acute asthma, positive pressure ventilation, or after Valsalva manoeuvres. The imaging method of choice is computed tomography, and its characteristic findings, interstitial emphysema adhering to a bronchus and pulmonary blood vessel. CONCLUSIONS: In the presence of pneumomediastinum and pneumoperitoneum is necessary to rule out oesophageal and tracheobronchial injury before establishing the Macklin effect as its cause. The diagnosis is made with computed tomography and managed conservatively.

latrogenic Mediastinal Emphysema and Subcutaneous Emphysema Induced by Bronchoscopic Examination.

A 79-year-old man presented with fever of unknown origin with interstitial shadows in the bilateral lung fields. A bronchoscopic examination did not indicate any malignancy or specific interstitial disease. After the bronchoscopic examination, the patient gradually developed subcutaneous and mediastinal emphysema. As the subcutaneous emphysema and mediastinal emphysema were mild, the patient was not administered any specific treatment. However, he eventually developed severe subcutaneous emphysema and mediastinal emphysema, and did not show any transient improvement. The patient underwent another bronchoscopic examination at another centre and a lacerated wound was detected. Thereafter, emergent operation was performed.

Recurrent spontaneous subcutaneous emphysema in a patient with rheumatoid arthritis.

Pulmonary air leak syndromes are extremely rare complications of systemic autoimmune connective tissue diseases and the occurrence of spontaneous subcutaneous emphysema (SSE) from pulmonary leak in the absence of pneumothorax or pneumomediastinum is even rarer. We report a case of recurrent SSE in a patient with rheumatoid arthritis and interstitial lung disease. The SSE was managed conservatively each time and it resorbed over several days. There has been no previous documented report of SSE in the absence of pneumomediastinum, pneumothorax or pulmonary nodules in a patient with RA.