5.

What is possibly complication that may happen in the early management and how to
solve it?

Subcutaneous emphysema

Air in subcutaneous fat tissue is called subcutaneous emphysema. Air can be from the
outside, from the lungs penetrate the visceral and parietal pleura into the subcutis or air
from the lungs to the mediastinum and to the subcutis without pleural damage.

Suppression of blood vessels due to air entering the pericardial cavity or in the blood vessels
in the neck so that it blocks blood returning to the heart.

- Signs and symptoms

Air bubbles in subcutaneous tissue, in the form of nodules that can be easily moved. Signs
and symptoms of subcutaneous emphysema vary depending on the cause, but are
sometimes accompanied by neck swelling, chest pain, difficulty swallowing, wheezing and
difficulty breathing. In certain cases, subcutaneous emphysema can be detected by touching
the skin in the area. At the touch will feel like tissue paper. When touched the bubble can
move and sometimes make a sound.

Subcutaneous emphysema is usually accompanied by swelling of the surrounding tissue.

Similarly, the patient's face. Because of the pressure caused by the swelling, the patient's
voice can change.

- Etiology

Subcutaneous emphysema is caused by blunt trauma or sharp trauma to the thorax wall.
When the pleural layer is hollow due to sharp trauma, air can move from the lungs to the
muscles and subcutaneous tissue in the chest wall. When rupture of the alveoli occurs, for
example in laceration of lung tissue, air can move along the visceral pleura to the lung's
hilum, then to the trachea, neck and chest wall. The foregoing can also occur in rib fractures
that injure lung tissue. Because rib fractures can tear the parietal pleura which can cause air
to move from the lungs to the subcutaneous tissue of the chest wall.

- therapy

Subcutaneous emphysema does not require special therapy. Action is taken if the amount of
air in the subcutaneous tissue is very large and affects the patient's breathing. The first thing
to do is to use a chest tube and make sure the chest tube is functioning properly (if the
cause is a pneumothorax). Installing a catheter or a small incision in the skin can help expel
air from subcutaneous tissue.
Shock

Shock is an emergency caused by the failure of blood perfusion to the tissues, resulting in
impaired cell metabolism. Death due to shock occurs when this condition causes
interference with nutrition and cell metabolism.

Hypovolemic shock is shock caused by blood loss or hemorrhagic shock.

- External hemorrhagic: trauma, gastrointestinal bleeding
- Internal hemorrhage: hematoma, hematothorax
The most common causes of hypovolemic shock are gastrointestinal mucosal bleeding and
severe trauma.

In patients with trauma, bleeding is usually suspected as a cause of shock. However, this
must be distinguished from other causes of shock. These include cardiac tamponade
(weakened heart sounds, neck venous distension), tension pneumothorax (tracheal
deviation, unilateral weakened breath sounds), and spinal cord trauma.

Hemothorax can occur in traumatic pneumothorax so that intravenous access with a large
cannula is required for fluid resuscitation if the patient experiences worsening to shock.
Apart from bleeding, obstructive shock can result from mediastinal shifting to the
contralateral side, compressing the contralateral lung and decreasing venous return.

Airway:
When examining the airway, note whether there is an airway obstruction such as the
presence of additional breath sounds such as gargling that indicates bleeding in the airways,
or stridor that indicates upper airway obstruction.

Breathing:
When assessing breathing efforts to consider are chest expansion, respiratory rate,
peripheral oxygen saturation. Asymmetrical chest expansion with rapid respiratory rate can
be found in pneumothorax. In traumatic pneumothorax, also evaluate the signs of trauma to
the chest, such as bruises, wounds, or subcutaneous emphysema.

Circulation:
Circulatory failure with shock signs such as hypotension, tachycardia, cold acral or cyanosis
indicates the possibility of pneumothorax tension or cardiac tamponade.

Oxygen Therapy
Give 100% oxygen immediately and maintain oxygen for the duration of treatment. High-
flow oxygen supplementation speeds up clinical pleural air absorption. By inhaling 100%
oxygen compared to free air, nitrogen alveolar pressure will decrease and nitrogen will
gradually be cleared of tissue and oxygen will enter the vascular system. With high
concentration of oxygen supplementation, normally 1.2% of the volume will be absorbed in
24 hours, 10% will be absorbed in 8 days and 20% in the next 16 days. Nitrogen gradient
differences that occur between capillary tissue and the pneumothorax chamber will
increase the absorption of the pleural cavity 4-fold.

Simple Aspirations
The point for aspiration is between the ribs 2 in the midclavicular line. It can also be done
between the anterior axillary 5 ribs to prevent life-threatening bleeding. needle aspiration
or intravenous cannula insertion is effective, comfortable, safe, and economical in some
patients.

Thoracostomy Hose or Intercostal Catheter

This procedure is recommended if simple aspiration is ineffective and thoracoscopy is not
available. Catheter / hose installation point is the same as simple aspiration needle
placement point. This procedure causes rapid lung expansion so that the duration of
treatment will be reduced. The risk of pulmonary re-expansion is that pulmonary edema will
be greater if re-expansion occurs too quickly so that the installation of water-seal is
recommended in the first 24 hours. Currently the installation of catheters more often
replaced with plastic hoses (18-24 Fr) compared to metal trokar because of the risk of injury.
The exact location of the hose can be seen from the presence of bubbles during expiration
and when coughing and increasing the level of water in the water seal at the time of
inspiration.

Reference :
- American College of Surgeon. Thoracic trauma. In: Advanced Trauma Life Support,
10th ed. 2018: 65-8.
- Faculty of Medicine, University of Indonesia. 1999. Capita Selekta Medicine, Jakarta:
Media Aesculapius.
- Faculty of Medicine, University of Indonesia. 1995. Collection of Surgery Studies,
Jakarta: Binarupa Aksara