Our institution, Loyola University Medical Center, is a nationally recognized quaternary-care system with a 61-acre main medical center campus in the western suburbs of Chicago. It houses a level 1 trauma center with the ability to provide top hospital care in all medical specialties.
A 27-year-old male with polytrauma was prepped for an open reduction internal fixation (ORIF) of a distal radius. Previous surgeries during his hospitalization were uncomplicated. Ultrasound scanning for identifiable anatomy revealed progressive accumulation of edema in the subcutaneous tissue appearing as branching, anechoic striations that impart a lobulated “cobblestone” appearance (Figure 1). Physical examination and subsequent chest X-ray confirmed the same. Lucency was present along the mediastinum consistent with pneumomediastinum and significant subcutaneous emphysema obscuring relevant block anatomy (Figure 2).
Without any reasonable explanation concerning the extensive crepitus, we decided to defer this non-urgent procedure. Later that evening, a computed tomography (CT) scan of the chest/abdomen/pelvis was performed revealing a large gas and fluid collection extending from the suprapubic region into the perineum, suggestive of a gangrenous infection (Figures 3-5). The patient was taken emergently to the OR for an exploratory laparotomy, which confirmed a large preperitoneal gas-forming abscess abutting previous pelvic hardware.
Implementing a solution
Anesthesia providers have been using bedside ultrasound for nerve blocks and vascular access for many years. Recently, there has been a call to incorporate whole-body point-of-care ultrasound (POCUS) in our training and daily practice. This POCUS technique entails developing and maintaining ongoing technical skills in image acquisition while understanding normal and altered sonoanatomy in a variety of pathologies.
Perioperative physical examination in combination with real-time ultrasound imaging for a supraclavicular block led to the inadvertent discovery of massive subcutaneous emphysema. Subcutaneous emphysema can occur when air is forced beneath the tissue, leading to swelling, crepitus on palpation, and potential spread along the fascial planes. Possible explanations in a post-trauma setting include rib fractures with lung laceration, pneumothorax, perforation of hollow viscus, esophageal/bowel rupture, tracheal/diaphragm perforation, and necrotizing infections. Anesthesiologists are familiar with appropriate management of non-extensive subcutaneous emphysema, depending on the underlying cause and clinical context. However, in cases of brisk and widespread gas expansion, it can be fatal.
Implications for massive subcutaneous emphysema include compartment syndrome, restricted thoracic wall expansion, tracheal compression, and tissue necrosis. Respiratory and cardiovascular complications can ensue, especially with the potential use of nitrous oxide and positive pressure ventilation.
The second lesson to be emphasized is the importance of assertive communication between specialties. Patient safety is at risk when health care professionals are not communicating effectively. By utilizing respectful, effective communication strategies, medical professionals can encourage collaboration and help prevent medical errors. This involves confidence, clarity, and control during the communication process.
Despite the inability of the surgical teams to explain the cause of the preoperative massive emphysema, they agreed with us that the procedure be deferred for further workup. The respectful exchange of thoughts, opinions, and information ultimately led to the correct interdisciplinary decision. In this context, we not only recognized the distorted anatomy, but we displayed a commitment to patient safety with effective communication and management of a life-threatening pelvic infection.
POCUS applications need to extend beyond the performance of nerve blocks and vascular access. Our case underscores the future need for expanding ultrasound education and practice for our colleagues and trainees through curriculum development, didactic teaching, informal bedside teaching, and simulations. Creating protocol-guided frameworks for POCUS can ensure a consistent and reliable method and interpretation of findings. The goal would be to secure a wider acceptance of POCUS through training and consider its use as an extension of the physical exam.