Subcutaneous emphysema (SE) is a potentially life-threatening complication derived from a pneumothorax. Treatment can be challenging and on an emergency basis. A 79-year-old patient was admitted with blunt chest trauma after a motor vehicle accident. Computed tomography showed incarceration of lung parenchyma in a fractured rib without pneumothorax. The patient was initially stable, but later on developed several episodes of acute dyspnea with bilateral pneumothoraces and life-threatening SE. Further assessment using chest X-ray was complicated by SE. Treatment consisted of chest tube insertion and additional vacuum-assisted closure (VAC) therapy of the SE using a pectoral incision. Symptoms resolved quickly, and chest tube and VAC-therapy could be discontinued by day 7 and 3, respectively. Immediate chest tube insertion is the first-line treatment for trauma patients with massive SE, even if a pneumothorax may not reliably be diagnosed initially. Supportive VAC-therapy must be considered to accelerate the decline of massive SE

Lieb, Sebastian

Meier, Christoph

Rudin, Mark

English

Atharva Scientific Publications (E-Jounals)

Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 188
Case Report
Vacuum-assisted closure therapy as adjunct to treatment of grotesque 
subcutaneous emphysema after blunt chest trauma: A case report
Sebastian Lieb1, Mark Rudin2, Christoph Meier3
1Resident, 2Consultant, 3Head of Traumatology, Department of Surgery, Clinic of Orthopaedic Surgery and Traumatology, Kantonsspital Winterthur, 
Brauerstr, 15, 8401 Winterthur, Switzerland
Correspondence to: Sebastian Lieb, Department of Surgery, Clinic of Orthopaedic Surgery and Traumatology, Kantonsspital Winterthur, 
Brauerstr, 15, 8401 Winterthur, Switzerland. E-mail: sebastianlieb@yahoo.com
Received – 15 March 2018 Initial Review – 03 April 2018 Published Online – 08 June 2018
Massive subcutaneous emphysema (SE) originating from the thorax and expanding to head and limbs following blunt chest trauma is a rare condition. Symptoms include 
crepitus, change in body contour, or impairment of sight due to 
swollen eyelids. Life-threatening compression of the trachea or 
the thorax along with critical impairment of respiration has been 
reported in the literature [1-4]. Normally, SE is associated with 
intrathoracic or mediastinal pathology, such as pneumothorax 
or lesions to the bronchi, trachea, or larynx [5,6]. Recalcitrant 
pneumothorax after pulmonary resection is the most common 
cause [7]. Most recommendations for the management of SE 
originate from thoracic surgeons. Chest-tube insertion is the first-line 
therapy [8]. However, other treatment options such as skin incisions, 
subcutaneous insertion of angiocatheters, liposuction devices, drains, 
and subcutaneous vacuum-assisted closure (VAC) therapy have been 
discussed mainly in case reports [2,5,7-10]. We present a case of SE 
following blunt chest trauma with a focus on the possible pitfalls in 
the diagnostic process and our experience with actual management 
recommendations from a trauma surgeon’s perspective.
CASE REPORT
A 79-year-old male sustained a blunt chest trauma when his car 
was involved in a frontal collision on a motorway. On admission, 
the patient was hemodynamically stable (blood pressure 
148/68 mmHg and heart rate 86 bpm), alert and fully oriented. 
His complaints were soreness in the neck and right ankle. The 
primary assessment according to the acute trauma and life support 
algorithm revealed an open airway and a protected cervical spine. 
Hematoma and crepitus over the sternum were noted along 
with a local tenderness of the sternum and the right parasternal 
region. Instability of the thoracic wall or respiratory distress was 
absent. Breath sounds were normal and symmetrical (respiratory 
rate 15/min and SaO2 96% with 8 L O2 intranasal).
The computed tomography (CT) trauma scan showed a 
minimally dislocated fracture of the manubrium sterni with 
accompanying retrosternal hematoma, serial right-sided rib 
fractures at the costochondral junction (ribs 2–8) with the 
incarceration of lung parenchyma in the fracture zone of the 
third rib (Fig. 1). Hemopneumothorax was excluded. The patient 
was admitted to the intermediate care (IMC) unit for further 
monitoring after a soft tissue injury on the right ankle was cleaned 
and the wound dressed. 6 hours after the injury, a sudden onset of 
dyspnea with an SE on the right side of the chest was observed. 
Chest X-ray revealed a left-sided pneumothorax and a vast SE on 
the contralateral side (Fig. 2). Insertion of a chest-tube into the 
left pleural space resulted in a quick improvement of the patient.
18 hours later, followed a second-look of the right ankle under 
general anesthesia to exclude a penetrating wound to the ankle 
joint. Surgical exploration showed a superficial wound and delayed 
closure was performed. After uneventful surgery and extubation, 
the patient developed another episode of agitation with dyspnea. 
ABSTRACT
Subcutaneous emphysema (SE) is a potentially life-threatening complication derived from a pneumothorax. Treatment can be 
challenging and on an emergency basis. A 79-year-old patient was admitted with blunt chest trauma after a motor vehicle accident. 
Computed tomography showed incarceration of lung parenchyma in a fractured rib without pneumothorax. The patient was initially 
stable, but later on developed several episodes of acute dyspnea with bilateral pneumothoraces and life-threatening SE. Further 
assessment using chest X-ray was complicated by SE. Treatment consisted of chest tube insertion and additional vacuum-assisted 
closure (VAC) therapy of the SE using a pectoral incision. Symptoms resolved quickly, and chest tube and VAC-therapy could be 
discontinued by day 7 and 3, respectively. Immediate chest tube insertion is the first-line treatment for trauma patients with massive 
SE, even if a pneumothorax may not reliably be diagnosed initially. Supportive VAC-therapy must be considered to accelerate the 
decline of massive SE.
Key words: Chest trauma, Pneumomediastinum, Pneumothorax, Subcutaneous emphysema, Vacuum-assisted closure - therapy
Lieb et al. Treatment of subcutaneous emphysema after blunt chest trauma
Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 189
Chest X-ray was repeated immediately and revealed progressive 
SE, now bilateral. Since right-sided pneumothorax could not 
be excluded as being the potential origin of the progressive SE, 
another chest tube was inserted into the right-sided pleural space. 
After the intervention, the patient recovered quickly. Observation 
for another 12 hours in the IMC unit was uneventful and the patient 
transferred to the trauma ward. Chest tubes were removed 1 (left) 
and 2 days later (right), with air leaks absent and SE reabsorbing.
After 1 day, the patient again complained of acute dyspnea 
with rapidly progressing SE including the whole torso and face. 
The massive swelling of the eyelids caused an inability to open the 
eyes leaving the patient temporarily blind. An urgent chest X-ray 
was inconclusive regarding pneumothorax due to the massive 
superimposition of the SE which made proper assessment impossible 
(Fig. 3). Therefore, bilateral chest tubes were inserted again. CT 
revealed no new bronchial or parenchymal lesions leaving the 
known lung tissue incarceration at the fracture site the only obvious 
source for the recurrent dyspnea and SE. Additional bronchoscopy 
also showed pathologies. To support reabsorption of the SE, a 5cm 
incision was applied over a large subcutaneous bulla in the right 
pectoral region under local anesthesia (Fig. 4). A VAC device was 
installed, and VAC therapy with the continuous negative pressure 
of 75 mmHg was initiated as described previously [1,11,12]. SE 
rapidly improved (Fig. 5). VAC therapy was discontinued after 
3 days. 2 and 3 days after that, the chest tubes were removed as well. 
The patient was finally discharged from the hospital 18 days after 
trauma with full recovery of SE. The later course was uneventful.
DISCUSSION
Thoracal SE starts with a lesion of the pulmonary parenchyma. 
In atraumatic situations with an intact chest wall, for example, 
spontaneous pneumothorax, there is leakage of air into the 
mediastinal space, and a pneumomediastinum may develop. This 
is observed in 70–90% of SE [13]. Further leakage will result in 
air being trapped and distributed along the fascial layers of the 
neck, face, torso, and finally the limbs. A life-threatening situation 
occurs when pneumothorax evolves into tension-pneumothorax. 
However, massive SE itself may be life-threatening when it 
causes compression of the cervical viscera or thoracic outlet 
obstruction [4,6,13]. This has been observed in cases of SE following 
tracheal injuries caused by a dog bite or kite string injuries [6,14]. 
In trauma or after thoracotomy with lesions of the parietal pleura, 
SE may occur directly without preceding pneumomediastinum. 
In our case, lung tissue was incarcerated between displaced rib 
fragments resulting in a delayed pneumothorax and SE.
Theoretically, SE could have developed without initial 
concomitant pneumothorax if the incarcerated lung tissue sealed 
the defect of the chest wall like a plug leaving only a direct 
connection between lung parenchyma and chest wall with the 
release of only small amounts of air into the soft tissues of the 
chest wall. One could speculate that the seal broke in the later 
course spontaneously or triggered by the mechanical ventilation 
leading to symptomatic pneumothorax and progressive SE. The 
development of SE from an initial parenchymal lesion to its clinical 
presentation can range from several hours to a few days [4,6]. 
Especially in the context of blunt chest trauma without an apparent 
wound or hematoma, SE can remain undiagnosed or misdiagnosed 
(e.g., as an anaphylactic shock) [8,11,12]. The occurrence of SE 
in a patient with chest trauma needs always a high suspicion of a 
concomitant pneumothorax. Therefore, establishing a safe airway 
and immediate chest tube insertion are crucial for the successful 
management of unstable patients with SE.
Establishing the diagnosis of pneumothorax in a patient 
with SE only by a clinical examination and chest X-rays can be 
challenging as demonstrated in our case. SE makes auscultation 
difficult, and superimposition of subcutaneous air may jeopardize 
interpretation of chest X-rays. CT is recommended in these cases 
for further evaluation if permitted by the condition of the patient. 
Mechanical ventilation with positive end-expiratory pressure 
(PEEP) in the presence of an air leak despite the insertion of a 
chest tube may also be a reason for progression of SE. We want 
to emphasize that in this situation continued PEEP ventilation 
without sufficient drainage of SE will finally lead to fatal 
compression of the airway or thoracic outlet obstruction.
Depending on the symptoms and dimension of SE, the 
physiological reabsorption of SE may be accelerated and 
supported by additional procedures. Different options have been 
Figure 1: Computed tomography performed on the patient’s 
admission shows fracture to manubrium sterni (red circle and left) 
and incarceration of lung parenchyma at the fractured costochondral 
junction of the third rib (red circle and right)
Figure 2: Chest X-ray performed after the first episode of dyspnea 
shows right-sided emphysema and left-sided pneumothorax (arrows)
Lieb et al. Treatment of subcutaneous emphysema after blunt chest trauma
Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 190
described. Increasing negative pressure on an existing chest 
tube or a second chest tube may also drain subcutaneous air [8]. 
Infraclavicular skin incisions (so-called blow-holes), optionally 
along with repeated massaging of the trapped air, subcutaneous 
insertion of large bore and specially prepared angiocatheters, 
liposuction devices, or Jackson-Pratt drains with suction have 
been described in various case presentations [3,7,9,10,15]. More 
recently, VAC-therapy applied in an infraclavicular incision has 
been proposed to deal with post-thoracotomy SE as described in 
the thoracic surgery literature [1,11,12].
Subcutaneous VAC-therapy is widely available. It is used in a 
vast number of different clinical settings and can be installed easily 
even under local anesthesia. The wound is sealed, and continuous 
negative pressure is applied to drain the subcutaneous air for 
several days without changing the dressing. Most of the authors 
propose the application of one VAC-drain as described in our 
case. However, bilateral placement has also been reported [11]. In 
most of the cases, a maximum of 4 days of VAC-therapy yielded a 
satisfying decline of SE. So far no complications of VAC-therapy 
for this specific indication such as occlusion of the drainage or 
bruising around the insertion site as seen with the other techniques 
have been observed [1,7,10-12].
CONCLUSION
Immediate chest tube insertion is the first-line treatment for trauma 
patients with massive SE, even if a pneumothorax may not reliably 
be diagnosed initially. Supportive VAC-therapy should always be 
considered to accelerate the decline of massive SE. However, this 
recommendation is based on a low level of evidence, since larger 
case series and studies with higher level of evidence are still lacking.
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Figure 3: (a) Clinical picture of the massive subcutaneous 
emphysema (SE) impairing sight (left). (b) Chest X-ray inconclusive 
for pneumothorax due to the superimposition of the SE (right)
Figure 4: Computed tomography showing a large subcutaneous bulla 
pectoral on the right side, next to the fractured third rib. Insertion 
site of the sponge for the vacuum-assisted closure-therapy
Figure 5: Clinical pictures of the decline of the subcutaneous 
emphysema under vacuum-assisted closure therapy (photos taken 
from day 1 to 3 and on day 7, starting left)
Funding: None; Conflict of Interest: None Stated.
How to cite this article: Lieb S, Rudin M, Meier C. Vacuum-assisted closure 
therapy as an adjunct to treatment of grotesque subcutaneous emphysema after 
blunt chest trauma: A case report. Indian J Case Reports. 2018;4(3):188-190.
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Vacuum-assisted closure therapy as adjunct to treatment of grotesque subcutaneous emphysema after blunt chest trauma: A case report

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Vacuum-assisted closure therapy as adjunct to treatment of grotesque subcutaneous emphysema after blunt chest trauma: A case report

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