Soft tissue and mediastinal emphysema
The entry of air into the connective tissue is a direct consequence of a closed lung rupture, and can also be observed in open pneumothorax, tracheal or esophageal rupture. Depending on the localization of the air accumulation, two main forms of the pathology are distinguished.
1. Subcutaneous emphysema Characterized by massive spread of air through the subcutaneous adipose tissue.
- Clinical presentation: visual examination reveals a sharp, unnatural increase in the patient's body volume. The edema spreads to the neck, face, and extremities.
- Diagnosis: the leading physical sign upon palpation is the crepitus sign — a characteristic crunching sound felt under the surgeon's fingers.
2. Mediastinal emphysema This is the most dangerous complication, requiring immediate response.
- Pathogenesis: air rapidly accumulates in the anatomical space of the mediastinum and the deep fascial spaces of the neck. This leads to mechanical compression of the great blood vessels and, consequently, severe circulatory disorders.
- Emergency treatment: immediate mediastinal drainage is indicated. The basic technique is cervical mediastinotomy. The surgeon makes a transverse skin incision directly above the jugular notch of the sternum. Next, blunt (digital) dissection of the tissue in the retrosternal space is performed, after which a tube is inserted into the formed channel for adequate decompression.
- With an increasing threat of asphyxia, the patient immediately undergoes endotracheal intubation or tracheostomy.
Conservative management and first aid
The general approach to the treatment of closed chest injuries is predominantly conservative. Any patient with such an injury must be immediately transported to a specialized surgical hospital.
Main directions of conservative therapy:
- Pain management: administration of systemic analgesics. For isolated or multiple rib fractures, local alcohol-procaine blockade, performed directly at the fracture site, has high efficacy.
- Relief of tension pneumothorax: the primary action is drainage of the pleural cavity to relieve pressure.
- General supportive therapy: includes the administration of cardiovascular drugs to stabilize hemodynamics and oxygen therapy.
Special attention is paid to maintaining airway patency. In case of excessive mucus accumulation and disruption of the natural drainage of the bronchial tree, toilet of the airways is indicated: therapeutic bronchoscopy or bronchial catheterization with active sputum suction. In the event of severe acute respiratory failure (ARF), the patient is transferred to mechanical ventilation. If prolonged ventilation and regular airway care are anticipated, a tracheostomy is performed.
Indications for emergency surgery
Despite the priority of conservative methods, there are a number of absolute indications for urgent surgical intervention — thoracotomy.
Surgical treatment is used in two key situations:
- Ongoing intrathoracic hemorrhage. The purpose of the surgery in this case is revision of the pleural cavity, detection of the source of blood loss, and reliable ligation of bleeding vessels.
- Valvular (tension) pneumothorax that does not resolve conservatively. If adequate drainage of the pleural cavity and active aspiration methods prove ineffective, thoracotomy is necessary for direct suturing of the lung wound that forms the valvular mechanism.
To remember the indications for urgent thoracotomy, use the "Two H's" rule: Hemorrhage (ongoing) and Valvular pneumothorax (refractory to drainage).
Class and exam questions
Why is mediastinal emphysema considered the most dangerous?
Air accumulating in the enclosed space of the mediastinum compresses the great blood vessels, which rapidly leads to critical circulatory disturbance and can cause death.
What is the essence of cervical mediastinotomy?
This is an emergency surgery for mediastinal decompression: an incision above the jugular notch, blunt digital dissection of the retrosternal tissue, and placement of a drainage tube to evacuate air.
Which method of anesthesia is specific for rib fractures?
For rib fractures, alcohol-procaine blockade is used, which is performed locally at the site of bone damage.
When is tracheostomy resorted to in chest trauma?
Tracheostomy is indicated when there is a threat of asphyxia against the background of emphysema, as well as to ensure prolonged mechanical ventilation and convenient bronchial hygiene in severe respiratory failure.
What else to study on this topic
- Mechanism of valvular pneumothorax formation in lung rupture
- Technique of performing alcohol-procaine blockade in rib fractures
- Equipment and operating principles of active pleural suction systems
- Features of therapeutic bronchoscopy in patients with severe chest trauma
- Pathophysiology of acute respiratory failure in closed chest trauma
Master the entire topic in the "General Surgery" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Chest Trauma" and another 3,335 pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 70 video lessons on the subject
Other topics in "CHAPTER 10. GENERAL ISSUES IN TRAUMATOLOGY"
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.