Pneumothorax With Soft Tissue Emphysema: CASE REPORT

In: Dental treatment

8 Jan 2010


A 37-year-old black male, 5′ 3″ and 128 pounds, with a history of moderate to severe mental retardation was scheduled for elective dental rehabilitation under general anesthesia in the operating room of a small state mental hospital. Preoperative testing included an electrocardiogram (ECG), complete blood count, electrolytes, chest x-ray (CXR), and a full health history and physical examination. The ECG revealed first-degree heart block, with all other tests being within normal limits. Previous dental procedures with general anesthesia were uneventful.

Figure 1. Submandibular subcutaneous emphysema

Figure 1. Submandibular subcutaneous emphysema (arrows) develops in the recovery room. Photo was taken after reintubation. Inset photograph was taken 2 months after the pneumothorax to compare with the preoperative soft tissue appearance.

Following intravenous (IV) access, the patient was premedicated with 0.2 mg glycopyrrolate and 8 mg DecadronĀ®. Monitoring included electrocardiography, pulse oximetry, end tidal C02, noninvasive blood pressure, and temperature. The patient, although restrained, would not allow a full-face mask for preoxygenation. A standard IV induction sequence involving lidocaine, propofol, d-tubocurare, and succinylcholine was used followed by a blind nasal intubation using a 7.0 nasal RAE. Bilateral breath sounds were confirmed. Anesthesia was initially maintained for the first 25 minutes with a combination of propofol (140 |jigAg/min) mixed with dopamine (2 |xgAg/min) and fentanyl (0.03 jxgAg/min) dispensed via a single syringe pump. The maintenance formula used was dictated by the protocol of an ongoing general anesthesia maintenance pilot drug study with which the patient was involved. After 25 minutes, the intravenous technique was discontinued and, for the remaining 25 minutes of the case, anesthesia was maintained using 1% isoflurane with 50% nitrous oxide (N20) and 50% oxygen (02) at a 2 L/min flow. Ventilation was assisted during induction, then was switched to controlled ventilation while dental radiographs were obtained. The controlled ventilation included a respiratory rate of 12, a peak inspiratory pressure of 20 cm H20, a tidal volume of 450-500 mL, and an end tidal C02 range of 30-35. The pulse oximetry range was 98-99% throughout the procedure. The patient was returned to spontaneous ventilation after 15 minutes of controlled ventilation, with the procedure subsequently being completed 15 minutes later.
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Figure 2. Mediastinum shifted

Figure 2. Mediastinum shifted to the patient’s right side with bifurcation of the trachea (single arrow); the outline of the opaque shadow demonstrates the collapsed lung (3 arrows).

Following completion of the procedure, 4 mL of 2% xylocaine with a 1:100,000 epinephrine dilution was given in the right and left maxillary posterior vestibules to reduce postoperative pain from dental extractions. The inhalational anesthetics (nitrous oxide and isoflurane) were discontinued and 100% 02 was delivered at a flow of 8 L/min. Because of the patient’s mental condition, an uncooperative wake-up was anticipated. Therefore, the patient was moved to a recovery bed and was carefully restrained with all monitors maintained in place. Bilateral breath sounds were reconfirmed following movement of patient, and he remained intubated.

After 10 minutes in the Post Anesthesia Care Unit (PACU), the patient suddenly sat upright and coughed and self-extubated. Neck, facial, and periorbital edema (Figure 1) developed within 10 minutes. Breathing became labored and Sa02 decreased to 88%. A provisional diagnosis of anaphylaxis to local anesthesia was considered. Solucortef (100 mg) and epinephrine (0.1 mg) were given intravenously. Chest auscultation (front and axial) revealed faint breath sounds on the left and breath sounds on the right but with expiratory wheezing. The patient was immediately returned to the operating room, induced, paralyzed, reintubated nasally, and placed on controlled ventilation. Following intubation, the patient had the same Sa02 of 88%, end tidal C02 of 41, and a normal sinus rhythm. Blood pressure was stable at 110/70 mm Hg with a 100-110 min heart rate. Clinically, chest expansion on the left was dispro portionately less than on the right. A portable chest radiograph (CXR) revealed a complete collapsed left lung and tracheal deviation to the left (Figure 2).

Figure 3. After needle thoracentesis

Figure 3. After needle thoracentesis, the trachea has shifted back to the midline and the lung has significantly reexpanded (3 arrows).

Muscle paralysis was continued with rocuronium, and the patient’s chest was prepared with iodine. An 18-gauge catheter-over-needle (14 gauge not available) was inserted into the fourth intercostal space at the midclavicular line with the confirmation of air under tension. Approximately 600 mL of air was withdrawn using a 60-mL syringe. Upon decompression of the chest, extension tubing was attached to the needle and an underwater seal was established. Following chest decompression, the Sa02 increased from 86 to 96%. A postdecompression CXR shows a normal midline trachea (Figure 3). Because the needle-catheter was smaller than the recommended 14 gauge, the needle was left inside the catheter for stability and prevention of collapse.Ā kamagra soft tablets

The operating facility did not have tubes available for chest thoracostomy, so the patient was transported to a local hospital emergency department. Prior to transport, 1 g of cefazolin was administered intravenously. The patient was transported with continued paralysis, assisted ventilation, and an Sa02 of 99-100%. Following chest-tube placement, the patient remained in the hospital for 5 days and was then discharged. Two weeks postoperatively, the patient was evaluated, with breath sounds and daily activity noted to be within normal limits.

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