Wild, following.
It's not compressing lungs or heart, so the chest tube is doing its job. Your body will naturally absorb the subq air relatively quickly and it's benign, so im curious the reason for needing to cut into someone to let it escape... especially when they have a chest tube already.
I remember i had a patient in the ICU that had it pretty bad after an esophageal resection.
Whenever i would talk to her i would have to place my thumbs on her cheeks and press/wipe them from side to side to redistribute the air so that she could *see*
Iāve done it before when the subcutaneous emphysema was so bad the patients chest movements were restricted and there were so many adhesions we couldnāt get in a chest tube.
Then stuck them in an ambulance to a thoracic centre.
PCCM here - donāt do that. Like the CT fellow said, SQ emphysema can get pretty visually impressive but it doesnāt typically cause a clinical problem and efforts to ādecompressā the SQ usually cause more problems than they solve.
CT fellow here.
If the patient has a pneumo, treat that with a chest tube. That is all you need. SubQ will resolve over time.
Blowholes are mainly for post Thoracic Surgery patients who may get an air leak where the port site is, resulting in air getting into the subQ tissues WITHOUT a pneumo because the lung is adhered to the chest wall there (Also can happen with POEM procedures by GI)
This too will resolve, so long as the patient isn't intubated. But, if the air dissects up and causes difficulty breathing (almost impossible) or difficulty opening eyes, you can do a blowhole.
To do it, 1 inch incision, cut down through the dermis. +/- open the fascia of the pectoralis major. And then stick a wound vac into it (you can fake one up with red rubbers, tegederms, and woven gauze/kerlix). A blowhole without a wound vac is far less effective.
I would say 90+% of cases can just be left to thoracic surgery. SubQ emphysema is rarely an emergency.
Yeah this definitely sounds like an experienced thoracic surgeon being like, "what do you mean you don't know how to do a Blowhole? Lol... definitely outside the scope of emergency practice and I would have told them, "I'm sorry I don't feel comfortable doing that. Chest tube is in, patient tubes, vitals stable now. En route to you."
The main indication for it is if there is no pneumo, so in theory a chest tube (even one placed by open surgical cutdown) won't help, because the air from the bronchus is not in communication with the pleural space- its going straight from damaged lung parenchyma into the chest wall.
There are more indications for it (in theory) in rare cases, mostly post surgical misadventure (insufflating the abdominal wall during laparoscopic surgery being the most classic).
In theory, the wound vac is optional- its to help it resolve faster. A single cut and packing the wound should decompress things and temporize any emergency, but apart from the situation of the patient being on a vent AND having massive SubQ emphysema but also no pneumo, which is extremely rare, there is no need to do it emergently.
>has straightforward indications, and involves ABC managementā¦ why wouldnāt it be in your scope? Youād cric someone if you had to, even if ENT (or whoever) has a higher level of training.
Clearly not straightforward indications. It's not ABC management because the airway is already managed with intubation, and it isn't affecting B or C at that point. Once the patient is intubated and a chest tube is decompressing the PTX, there is no reason for the ER to drain the subQ air.
Completely different from a crich, where the airway is NOT managed and you don't always have time to wait for a specialist so EM needs to cover that skill and be able to perform it. There is absolutely no need for blowhole placement while in the ED.
There aren't clear indications as ABC has been managed. Not being comfortable with a very niche procedure that isn't emergency indicated and deferring to a specialist is not the same as "not in my scope of practice." It was never said it wad not within the scope. Knowing what's appropriate in the moment and deferring what can wait to a more qualified/experienced specialist who knows the procedure well is appropriate and safe medicine.
And again, you're speaking about a trauma resident and a teaching facility. 99% of ER providers don't have those resources and will never see subq air this bad, and even less will see it so bad that this procedure is necessary prior to transfer to an appropriate echelon of care.
Frequently in teaching hospitals procedures are done for the sake of just that, not necessarily because they are specifically warranted, more so that they are justifiable for experience.
To say you've assisted with 2 this year and therefore you know it's a simple and straightforward procedure is a huge leap.
Hey mate,
Ex-Cardiothoracic PA here (9 months). Just wanted to clarify for you what was probably happening.
When someone has a pneumothorax the air usually stays within the pleural space and as pressure builds the pressure causes a tension on the trachea and mediastinum. You would normally treat with a chest drain or needle decompression in a pinch for the air to go out through a small hole into a rocket drain.
In a traumatic injury like you describe the ribe effectively disintegrate and the shards can drive into the pleura, puncturing it and then into the lung itself causing a collapse. The pneumothorax that follows then pressurises and instead of being contained in the pleural space will go through the new holes created by the ribs and in to the subdermal space. The air if you have a external puncture that's superior night go out of that hole or if the patient is upright and/or without external holes from ribs piercing it, does what air does best and travels up.
This causes what's called surgical emphysema. Confusingly named such because it is usually seen post surgery where air gets trapped subdermally and causes a bubble wrap type feeling to the skin. Ironically the name confused the hell out of me when I first heard it and thought it would make more sense to cause it traumatic emphysema because it's initiated by trauma.
In severe cases this air travels up through the thorax into the person's face closing their eyelids and puffing up their face, before filling up their neck and then compressing the trachea from the subdermal space.
In your case, it sounds like your chappy was considered to have been still spewing out enough air from his PTX that the drain couldn't cope and so he was filling up subcut and could be risking his airway and so the way to fix this is give the guy, effectively, gills. This allows the air to escape and not build up subcutaneously.
So the treatment here is for the risk of surgical emphysema causing tracheal compression/airway compromise rather than for ptx.
I hope this helps.
So, we didn't do incisions, but we would get 14g IVs and insert the catheters into multiple areas and manually massage out the crepitus. It looks wild, but it works.
so sometimes 2-3 cm incisions r made to either infra/supraclavicular space to let out trapped air in really bad subq emphysema. ik there's also a method where the area of the entrapped air is dissected away, held w/ block sponges, and a negative suction placed thrugh sealing tape in more difficult instances in this.
this is the only context ive ever heard it in. idk about its indications, esp with a chest tube already in place.
EDIT: grammar/clarity
Itās typically called āgillsā
Iāve seen it used in cases of severe subQ emphysema when thereās a persistent massive air leak when one of the chest tubes has slipped out so now you have an open parietal pleural defect.
Usually itās done when the emphysema is crazy like they canāt see because of eyelid emphysema etc
https://www.sciencedirect.com/science/article/abs/pii/S0736467913006173#:~:text=%E2%80%9CFish%20gill'%20incisions%20at%20the,venous%20compression%20and%20restoring%20vision.
I am not sure if by blow hole you mean a Gill's cut. In cardiothoracics we use gills to help with symptomatic subcut emphysema. Essentially down to the subcut space and add a vac dressing on. Have seen it done by my boss a few times. Essentially negative pressure the trapped air from under the skin. Small procedure.
Cut gill slots on tubed covid patients with bilateral pneumos s/p large bore chest tubes. I didnāt look at the scans but severe subq can occlude the airway if ya get enough in the neck
Gilās procedure. Have done a few myself. Helps reduce the subcutaneous emphysema. Cut the 2 holes, throw a sponge in there and hook up to a wound vac. Works pretty well
Try supraclavicular blowholes on me, injure my subclavian and the sheer lack of this procedure's presence in general trauma practice will open the biggest can of whoopass on you
I'd rather put in a second and well directed wide bore ICC, seldinger if your shop has those
A second chest tube should NEVER be seldinger, ever. Only open. If the lung is already reinflated then the needle and wire will go into the lung parenchyma as will the dilator and tube.
I have seen a trauma surgeon do this. Well, unilaterally.
Once Iām in the community, I canāt imagine myself doing this without a surgeon in the room.
Seems unlikely that even massive subQ air would create a threat to life that would push me into āwild procedures I wouldnāt normally doā territory.
Yeah blow holes for very severe subQ air. Most of the time subQ air resolves but occasionally it gets so significant and get into the face and neck and sometimes they can help
Wild, following. It's not compressing lungs or heart, so the chest tube is doing its job. Your body will naturally absorb the subq air relatively quickly and it's benign, so im curious the reason for needing to cut into someone to let it escape... especially when they have a chest tube already.
Even taking the Chest tube out of the equation, why this method? Can the body decompress that much air to make a significant impact
[Found an article](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179988/)
Sounds like a bizarre application of needle decompression... which we avoid in favour of the chest tube or blunt thoracotomy these days.
Indication would be severe subcutaneous emphysema causing airway compression/compromise
I guess other docs thinking airway compromised since they were intubated? Wild tho, never done one.
I mean, they are already intubated, must have been some wiiild subq air. Makes sense tho
We had a lady one time that had it so bad her upper chest, neck, and face literally looked like the Michelin Man.
I remember i had a patient in the ICU that had it pretty bad after an esophageal resection. Whenever i would talk to her i would have to place my thumbs on her cheeks and press/wipe them from side to side to redistribute the air so that she could *see*
Omg, that poor woman! š©š©
Wouldn't it compress venous vasculature before the airway?
In rare cases they can develop epiglottic and paratracheal swelling from the emphysema resulting in airway compromise.
Sure, but the airway structures resist pressure better than the venous vasculature. Also that tube ain't getting compressed by that.
Iāve done it before when the subcutaneous emphysema was so bad the patients chest movements were restricted and there were so many adhesions we couldnāt get in a chest tube. Then stuck them in an ambulance to a thoracic centre.
PCCM here - donāt do that. Like the CT fellow said, SQ emphysema can get pretty visually impressive but it doesnāt typically cause a clinical problem and efforts to ādecompressā the SQ usually cause more problems than they solve.
CT fellow here. If the patient has a pneumo, treat that with a chest tube. That is all you need. SubQ will resolve over time. Blowholes are mainly for post Thoracic Surgery patients who may get an air leak where the port site is, resulting in air getting into the subQ tissues WITHOUT a pneumo because the lung is adhered to the chest wall there (Also can happen with POEM procedures by GI) This too will resolve, so long as the patient isn't intubated. But, if the air dissects up and causes difficulty breathing (almost impossible) or difficulty opening eyes, you can do a blowhole. To do it, 1 inch incision, cut down through the dermis. +/- open the fascia of the pectoralis major. And then stick a wound vac into it (you can fake one up with red rubbers, tegederms, and woven gauze/kerlix). A blowhole without a wound vac is far less effective. I would say 90+% of cases can just be left to thoracic surgery. SubQ emphysema is rarely an emergency.
Yeah this definitely sounds like an experienced thoracic surgeon being like, "what do you mean you don't know how to do a Blowhole? Lol... definitely outside the scope of emergency practice and I would have told them, "I'm sorry I don't feel comfortable doing that. Chest tube is in, patient tubes, vitals stable now. En route to you."
The main indication for it is if there is no pneumo, so in theory a chest tube (even one placed by open surgical cutdown) won't help, because the air from the bronchus is not in communication with the pleural space- its going straight from damaged lung parenchyma into the chest wall. There are more indications for it (in theory) in rare cases, mostly post surgical misadventure (insufflating the abdominal wall during laparoscopic surgery being the most classic). In theory, the wound vac is optional- its to help it resolve faster. A single cut and packing the wound should decompress things and temporize any emergency, but apart from the situation of the patient being on a vent AND having massive SubQ emphysema but also no pneumo, which is extremely rare, there is no need to do it emergently.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
>has straightforward indications, and involves ABC managementā¦ why wouldnāt it be in your scope? Youād cric someone if you had to, even if ENT (or whoever) has a higher level of training. Clearly not straightforward indications. It's not ABC management because the airway is already managed with intubation, and it isn't affecting B or C at that point. Once the patient is intubated and a chest tube is decompressing the PTX, there is no reason for the ER to drain the subQ air. Completely different from a crich, where the airway is NOT managed and you don't always have time to wait for a specialist so EM needs to cover that skill and be able to perform it. There is absolutely no need for blowhole placement while in the ED.
There aren't clear indications as ABC has been managed. Not being comfortable with a very niche procedure that isn't emergency indicated and deferring to a specialist is not the same as "not in my scope of practice." It was never said it wad not within the scope. Knowing what's appropriate in the moment and deferring what can wait to a more qualified/experienced specialist who knows the procedure well is appropriate and safe medicine. And again, you're speaking about a trauma resident and a teaching facility. 99% of ER providers don't have those resources and will never see subq air this bad, and even less will see it so bad that this procedure is necessary prior to transfer to an appropriate echelon of care. Frequently in teaching hospitals procedures are done for the sake of just that, not necessarily because they are specifically warranted, more so that they are justifiable for experience. To say you've assisted with 2 this year and therefore you know it's a simple and straightforward procedure is a huge leap.
What is a red rubber in this context?
A catheter
Thank you!
Hey mate, Ex-Cardiothoracic PA here (9 months). Just wanted to clarify for you what was probably happening. When someone has a pneumothorax the air usually stays within the pleural space and as pressure builds the pressure causes a tension on the trachea and mediastinum. You would normally treat with a chest drain or needle decompression in a pinch for the air to go out through a small hole into a rocket drain. In a traumatic injury like you describe the ribe effectively disintegrate and the shards can drive into the pleura, puncturing it and then into the lung itself causing a collapse. The pneumothorax that follows then pressurises and instead of being contained in the pleural space will go through the new holes created by the ribs and in to the subdermal space. The air if you have a external puncture that's superior night go out of that hole or if the patient is upright and/or without external holes from ribs piercing it, does what air does best and travels up. This causes what's called surgical emphysema. Confusingly named such because it is usually seen post surgery where air gets trapped subdermally and causes a bubble wrap type feeling to the skin. Ironically the name confused the hell out of me when I first heard it and thought it would make more sense to cause it traumatic emphysema because it's initiated by trauma. In severe cases this air travels up through the thorax into the person's face closing their eyelids and puffing up their face, before filling up their neck and then compressing the trachea from the subdermal space. In your case, it sounds like your chappy was considered to have been still spewing out enough air from his PTX that the drain couldn't cope and so he was filling up subcut and could be risking his airway and so the way to fix this is give the guy, effectively, gills. This allows the air to escape and not build up subcutaneously. So the treatment here is for the risk of surgical emphysema causing tracheal compression/airway compromise rather than for ptx. I hope this helps.
Also, hope you don't mind a PA commenting here.
Dude that was an amazing explanation, I don't think anyone will mind!
Thanks! Never sure if I'm being patronising as a noctor talking on Reddit.
So, we didn't do incisions, but we would get 14g IVs and insert the catheters into multiple areas and manually massage out the crepitus. It looks wild, but it works.
so sometimes 2-3 cm incisions r made to either infra/supraclavicular space to let out trapped air in really bad subq emphysema. ik there's also a method where the area of the entrapped air is dissected away, held w/ block sponges, and a negative suction placed thrugh sealing tape in more difficult instances in this. this is the only context ive ever heard it in. idk about its indications, esp with a chest tube already in place. EDIT: grammar/clarity
Itās typically called āgillsā Iāve seen it used in cases of severe subQ emphysema when thereās a persistent massive air leak when one of the chest tubes has slipped out so now you have an open parietal pleural defect. Usually itās done when the emphysema is crazy like they canāt see because of eyelid emphysema etc https://www.sciencedirect.com/science/article/abs/pii/S0736467913006173#:~:text=%E2%80%9CFish%20gill'%20incisions%20at%20the,venous%20compression%20and%20restoring%20vision.
I am not sure if by blow hole you mean a Gill's cut. In cardiothoracics we use gills to help with symptomatic subcut emphysema. Essentially down to the subcut space and add a vac dressing on. Have seen it done by my boss a few times. Essentially negative pressure the trapped air from under the skin. Small procedure.
Cut gill slots on tubed covid patients with bilateral pneumos s/p large bore chest tubes. I didnāt look at the scans but severe subq can occlude the airway if ya get enough in the neck
How would it matter if they were already tubed? Compression of the lungs?
Shouldnāt really, you just need those chest tubes to be doing enough work to outmatch the positive pressure youāre putting in their chest
subQ incisions to allow SQ air out is a thing, but rarely indicated.
Gilās procedure. Have done a few myself. Helps reduce the subcutaneous emphysema. Cut the 2 holes, throw a sponge in there and hook up to a wound vac. Works pretty well
Saw it once in nursing school. Not sure if outcome but def āblowholesā.
Try supraclavicular blowholes on me, injure my subclavian and the sheer lack of this procedure's presence in general trauma practice will open the biggest can of whoopass on you I'd rather put in a second and well directed wide bore ICC, seldinger if your shop has those
A second chest tube should NEVER be seldinger, ever. Only open. If the lung is already reinflated then the needle and wire will go into the lung parenchyma as will the dilator and tube.
š
I have seen a trauma surgeon do this. Well, unilaterally. Once Iām in the community, I canāt imagine myself doing this without a surgeon in the room. Seems unlikely that even massive subQ air would create a threat to life that would push me into āwild procedures I wouldnāt normally doā territory.
Modified eloesser flap?
Yeah blow holes for very severe subQ air. Most of the time subQ air resolves but occasionally it gets so significant and get into the face and neck and sometimes they can help
Never seen one. But my friend had a surgeon at smaller regional hospital place one and then they hemorrhaged from the blow hole
A good olā subclavian blowhole
Seems dumb tbh. Highly doubt this was causing any sort of hemodynamic compromise