Subcutaneous Emphysema

The other day we had a patient with the most profound subcutaneous emphysema any of us had ever seen. The patient stated he’d just stumbled and hit the edge of a chair with his chest wall several days prior to presentation, then noticed he was “slowly getting bigger”. The family at the bedside all agreed that he was much bigger than usual.

On physical exam, he had normal vital signs, was in no distress, but had ‘the SQ crackles’ (crepitance) everywhere, and that’s not an exaggeration. Crepitance due to subcutaneous emphysema feels like popping tiny packing bubbles when compressed, and is usually limited to a fairly small area unless the patient is on the ventillator or getting positive pressures in the airway for some other reason.

Our patient got a CT to find where the air was coming from, and if there were other injuries. Here’s 3 slices from his CT:

upper chest
So, in the upper chest he has a respectable amount of SQ air, a pneumomediastinum, and air in other places.

mid-abdomen
In the mid-abdomen the air continues, as well as being found in the back muscles.

oh, no
Here’s the part we didn’t expect: air in the skin of the penis, along with more SQ air.

He had crepitance literally everywhere, down to the tops of his feet. He got a right-sided chest tube for a pneumothorax that was felt to be the cause, and went upstairs.