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Emfisema subkutanUdara di lemak subkutan dinamakan emfisema subkutan.

Udara dapat dari


luar,dari parumenembus pleura visceralis dan parietalis masuk ke subkutis atau udara dari paru
kemediastinum dan ke subkutis tanpa ada kerusakan pleura.Harus diingat bahwa pnumothorax
sering disertai emfisema subkutan, dan emfisemaseringkali disertai pneumothorax. Bila ada
emfisema subkutan adanya pneumothoraxsukar dicari baik secara fisik maupun radiologik. Oleh
karena itu, bila ada emfisemasubkutan harus dengan sengaja dicari adanya pneumothorax.
Biasanya tempat yang baik untuk melihat adanya pneumothorax yang paling baik adalah di
pinggir dinding dadayang dibatasi oleh segi empat yang dibentuk oleh iga-igaBila ada emfisema
subkutan tidak perlu tindakan pembedahan,tetapi perlu pasien ataukeluarganya diberitahu
kemungkinan akan menyebabkan muka menjadi bengkak, danagak lama menghilang. Emfisema
subkutan perlu tidakan bila emfisema sifatnya progresif atau adanya tanda-tanda penekanan
pembuluh darah balik dada ke atas.Progresif biasanya karena adanya kerusakan bronchus atau
trachea, suatu keadaan ygmemerlukan tindakan pembedahan segera untuk repair kerusakan yang
terjadi,olehkarena itu dicari penyebab bila progresif. Penekanan pembuluh darah balik karena
udaramasuk ke rongga perikardium atau di sarung pembuluh darah di leher
sehinggamenghambat darah yang kembali ke jantung, suatu keadaan yang sama seperti
padatamponade jantung. Keadaan ini dapat dibebaskan dengan mediastinomi dan
membukasarung pembuluh darah.
Tanda dan gejalaGelembung uadara di jaringan subcutan, berupa nodul yang mobil yang dapat
denganmudah digerakkan. Tanda dan gejala dari emfisema subkutan bevariasi bergantung
pada penyebabnya,
tapi
terkadang
disertai
dengan
pembekakan
leher,nyeri
dada,kesulitanmenelan, wheezing dan kesulitan bernafas. Dari foto thorax bisa diketahui adanya
udaradi cavum mediastinum. Pada kasus-kasus tertentu, emfisema subkutan dapat
dideteksidengan meraba kulit di daerah tersebut. Pada perabaan tersebut akan terasa seperti
kertastisu. Saat diraba gelembung tersebut dapat berpindah dan terkadang menimbulkan suara
Emfisema subkutanUdara di lemak subkutan dinamakan emfisema subkutan. Udara
dapat dari luar,dari parumenembus pleura visceralis dan parietalis masuk ke
subkutis atau udara dari paru kemediastinum dan ke subkutis tanpa ada kerusakan
pleura.Harus diingat bahwa pnumothorax sering disertai emfisema subkutan, dan
emfisemaseringkali disertai pneumothorax. Bila ada emfisema subkutan adanya
pneumothorax sukar dicari baik secara fisik maupun radiologik. Oleh karena itu, bila
ada emfisemasubkutan harus dengan sengaja dicari adanya pneumothorax.
Biasanya tempat yang baik untuk melihat adanya pneumothorax yang paling baik
adalah di pinggir dinding dadayang dibatasi oleh segi empat yang dibentuk oleh
iga-igaBila ada emfisema subkutan tidak perlu tindakan pembedahan,tetapi perlu
pasien ataukeluarganya diberitahu kemungkinan akan menyebabkan muka menjadi
bengkak, danagak lama menghilang. Emfisema subkutan perlu tidakan bila
emfisema sifatnya progresif atau adanya tanda-tanda penekanan pembuluh darah
balik dada ke atas.Progresif biasanya karena adanya kerusakan bronchus atau
trachea, suatu keadaan ygmemerlukan tindakan pembedahan segera untuk repair

kerusakan yang terjadi,olehkarena itu dicari penyebab bila progresif. Penekanan


pembuluh darah balik karena udaramasuk ke rongga perikardium atau di sarung
pembuluh darah di leher sehinggamenghambat darah yang kembali ke jantung,
suatu keadaan yang sama seperti padatamponade jantung. Keadaan ini dapat
dibebaskan dengan mediastinomi dan membukasarung pembuluh darah.Tanda dan
gejalaGelembung uadara di jaringan subcutan, berupa nodul yang mobil yang dapat
denganmudah digerakkan. Tanda dan gejala dari emfisema subkutan bevariasi
bergantung pada penyebabnya, tapi terkadang disertai dengan pembekakan
leher,nyeri dada,kesulitanmenelan, wheezing dan kesulitan bernafas. Dari foto
thorax bisa diketahui adanya udaradi cavum mediastinum. Pada kasus-kasus
tertentu, emfisema subkutan dapat dideteksidengan meraba kulit di daerah
tersebut. Pada perabaan tersebut akan terasa seperti kertastisu. Saat diraba
gelembung tersebut dapat berpindah dan terkadang menimbulkan suara. Emfisema
subkutan biasanya disertai pembengkakan jaringan di sekitarnya. Begitu
puladengan wajah pasien. Oleh karena penekanan akibat pembengkakan
tersebut,suara pasiendapat berubah.EtiologiEmfisema subkutis disebabkan oleh
trauma tumpul maupun trauma tajam pada dindingthorax. Ketika lapisan pleura
berlubang akibat trauma tajam, udara dapat berpindah dari paru-paru menuju otot
dan jaringan subkutan pada dinding dada. Ketikan terjadi ruptur pada
alveoli,misalkan pada laserasi jaringan paru, udara dapat berpindah sepanjang
pleura visceralis menuju hilum paru-paru, kemudian menuju trachea, leher dan
dindingdada. Hal tersebut di atas bisa pula terjadi pada fraktur costae yang melukai
jaringan paru. Sebab fraktur costa dapat merobek pleura parietalis yang bisa
menyebabkan udara berpindah dari paru ke jaringan subkutis dinding
dada.TatalaksanaEmfisema subkutis tidak memerlukan terapi khusus. Tindakan
dilakukan apabila jumlahudara dalam jaringan subkutis sangat banyak dan
mempengaruhi pernafasan pasien. Hal pertama yang harus dilakukan adalah
memasang chest tube dan memastikan chest tubetersebut berfungsi baik ( bila
penyebabnya dalah pneumothorax ). Pemasangan kateter atau insisi kecil pada kulit
dapat membantu mengeluarkan udara dari jaringan subkutan

Subcutaneous emphysema
From Wikipedia, the free encyclopedia
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Subcutaneous emphysema
Classification and external resources

An abdominal CT scan of a patient with subcutaneous


emphysema (arrows)
ICD-10
T79.7, T81.8
ICD-9
958.7, 998.81
DiseasesDB
29756
MedlinePlus
003286
MeSH
D013352
Subcutaneous emphysema, sometimes abbreviated SCE or SE and also called tissue
emphysema, or Sub Q air, occurs when gas or air is present in the subcutaneous layer of the
skin. Subcutaneous refers to the tissue beneath the cutis of the skin, and emphysema refers to
trapped air. Since the air generally comes from the chest cavity, subcutaneous emphysema
usually occurs on the chest, neck and face, where it is able to travel from the chest cavity along
the fascia.[1] Subcutaneous emphysema has a characteristic crackling feel to the touch, a
sensation that has been described as similar to touching Rice Krispies;[2] this sensation of air
under the skin is known as subcutaneous crepitation.
Pneumomediastinum was first recognized as a medical entity by Laennec who reported it as a
consequence of trauma in 1819. This complication has many causes. It was well described Dr.
Louis Hamman in the 1939 in woman after labor and delivery at The Johns Hopkins Hospital. It
is sometimes called Hamman's syndrome though usually referred by thoracic surgeons and
pulmonologists as Macklin's Syndrome. First reported by L. Macklin in 1939 and later by M.T.
Macklin and C.C. Macklin in 1944, the latter two explained the pathophysiology in more detail.[3]
Subcutaneous emphysema can result from puncture of parts of the respiratory or gastrointestinal
systems. Particularly in the chest and neck, air may become trapped as a result of penetrating
trauma (e.g., gunshot wounds or stab wounds) or blunt trauma. Infection (e.g., gas gangrene) can
cause gas to be trapped in the subcutaneous tissues. Subcutaneous emphysema can be caused by
medical procedures and medical conditions that cause the pressure in the alveoli of the lung to be
higher than that in the tissues outside of them.[4] Its most common causes are pneumothorax and
a chest tube that has become occluded by a blood clot or fibrinous material. It can also occur
spontaneously due to rupture of the alveoli with dramatic presentation.[5] When the condition is
caused by surgery it is called surgical emphysema.[6] The term spontaneous subcutaneous
emphysema is used when the cause is not clear.[5] Subcutaneous emphysema is not typically
dangerous in and of itself, however it can be a symptom of very dangerous underlying
conditions, such as pneumothorax.[7] Although the underlying conditions require treatment,

subcutaneous emphysema usually does not; small amounts of air are reabsorbed by the body.
However, subcutaneous emphysema can be uncomfortable and may interfere with breathing, and
is often treated by removing air from the tissues, for example by using large bore needles, skin
incisions or subcutaneous catheterization.

Contents

1 Symptoms and signs


2 Causes
o

2.1 Trauma

2.2 Medical treatment

2.3 Infection

3 Pathophysiology

4 Diagnosis

5 Treatment

6 Prognosis

7 History

8 References

Symptoms and signs

A case of subcutaneous emphysema of the scrotum following rib fractures.

Signs and symptoms of spontaneous subcutaneous emphysema vary based on the cause, but it is
often associated with swelling of the neck and chest pain, and may also involve sore throat, neck
pain, difficulty swallowing, wheezing and difficulty breathing.[5] Chest X-rays may show air in
the mediastinum, the middle of the chest cavity.[5] A significant case of subcutaneous emphysema
is easy to detect by touching the overlying skin; it feels like tissue paper or Rice Krispies.[8]
Touching the bubbles causes them to move and sometimes make a crackling noise.[9] The air
bubbles, which are painless and feel like small nodules to the touch, may burst when the skin
above them is palpated.[9] The tissues surrounding SCE are usually swollen. When large amounts
of air leak into the tissues, the face can swell considerably.[8] In cases of subcutaneous
emphysema around the neck, there may be a feeling of fullness in the neck, and the sound of the
voice may change.[10] If SCE is particularly extreme around the neck and chest, the swelling can
interfere with breathing. The air can travel to many parts of the body, including the abdomen and
limbs, because there are no separations in the fatty tissue in the skin to prevent the air from
moving.[11]

Causes
Trauma
Conditions that cause subcutaneous emphysema may result from both blunt and penetrating
trauma;[5] SCE is often the result of a stabbing or gunshot wound.[12] Subcutaneous emphysema is
often found in car accident victims because of the force of the crash.
Chest trauma, a major cause of subcutaneous emphysema, can cause air to enter the skin of the
chest wall from the neck or lung.[9] When the pleural membranes are punctured, as occurs in
penetrating trauma of the chest, air may travel from the lung to the muscles and subcutaneous
tissue of the chest wall.[9] When the alveoli of the lung are ruptured, as occurs in pulmonary
laceration, air may travel beneath the visceral pleura (the membrane lining the lung), to the hilum
of the lung, up to the trachea, to the neck and then to the chest wall.[9] The condition may also
occur when a fractured rib punctures a lung;[9] in fact, 27% of patients who have rib fractures also
have subcutaneous emphysema.[11] Rib fractures may tear the parietal pleura, the membrane
lining the inside of chest wall, allowing air to escape into the subcutaneous tissues.[13]
Subcutaneous emphysema is frequently found in pneumothorax (air outside of the lung in the
chest cavity)[14][15] and may also result from air in the mediastinum, pneumopericardium (air in
the pericardial cavity around the heart).[16] A tension pneumothorax, in which air builds up in the
pleural cavity and exerts pressure on the organs within the chest, makes it more likely that air
will enter the subcutaneous tissues through pleura torn by a broken rib.[13] When subcutaneous
emphysema results from pneumothorax, air may enter tissues including those of the face, neck,
chest, armpits, or abdomen.[1]
When subcutaneous emphysema occurs with pneumomediastinum, the condition is known as
Hamman's syndrome.[17] Pneumomediastinum can result from a number of events. For example,
foreign body aspiration, in which someone inhales an object, can cause pneumomediastinum
(and lead to subcutaneous emphysema) by puncturing the airways or by increasing the pressure
in the affected lung(s) enough to cause them to burst.[18]

Subcutaneous emphysema of the chest wall is commonly among the first signs to appear that
barotrauma, damage caused by excessive pressure, has occurred,[1][19] and it is an indication that
the lung was subjected to significant barotrauma.[20] Thus the phenomenon may occur in diving
injuries.[5][21]
Trauma to parts of the respiratory system other than the lungs, such as rupture of a bronchial
tube, may also cause subcutaneous emphysema.[13] Air may travel upward to the neck from a
pneumomediastinum that results from a bronchial rupture, or downward from a torn trachea or
larynx into the soft tissues of the chest.[13] It may also occur with fractures of the facial bones,
neoplasms, during asthma attacks, when the Heimlich maneuver is used, and during childbirth.[5]
It is estimated to occur with pneumomediastinum in one in every 2000100,000 deliveries.[17]
Injury with pneumatic tools, those that are driven by air, is also known to cause subcutaneous
emphysema, even in extremities (the arms and legs).[22] It can also occur as a result of rupture of
the esophagus; when it does, it is usually as a late sign.[23]

Medical treatment
Subcutaneous emphysema is a common result of certain types of surgery; for example it is not
unusual in chest surgery.[8] It may also occur from surgery around the esophagus, and is
particularly likely in prolonged surgery.[7] Other potential causes are positive pressure ventilation
for any reason and by any technique, in which its occurrence is frequently unexpected. It may
also occur as a result of dental surgery,[24] laparoscopy,[7] and cricothyrotomy. In a
pneumonectomy, in which an entire lung is removed, the remaining bronchial stump may leak
air, a rare but very serious condition that leads to progressive subcutaneous emphysema.[8] Air
can leak out of the pleural space through an incision made for a thoracotomy to cause
subcutaneous emphysema.[8] On infrequent occasions, the condition can result from dental
surgery, usually due to use of high-speed tools that are air driven.[25] These cases result in usually
painless swelling of the face and neck, with an immediate onset, the crepitus (crunching sound)
typical of subcutaneous emphysema, and often with subcutaneous air visible on X-ray.[25]
One of the main causes of subcutaneous emphysema, along with pneumothorax, is an improperly
functioning chest tube.[2] Thus subcutaneous emphysema is often a sign that something is wrong
with a chest tube; it may be clogged, clamped, or out of place.[2] The tube may need to be
replaced, or, when large amounts of air are leaking, a new tube may be added.[2]
Since mechanical ventilation can worsen a pneumothorax, it can force air into the tissues; when
subcutaneous emphysema occurs in a ventilated patient, it is an indication that the ventilation
may have caused a pneumothorax.[2] It is not unusual for subcutaneous emphysema to result from
positive pressure ventilation.[26] Another possible cause is a ruptured trachea.[2] The trachea may
be injured by tracheostomy or tracheal intubation; in cases of tracheal injury, large amounts of air
can enter the subcutaneous space.[2] An endotracheal tube can puncture the trachea or bronchi and
cause subcutaneous emphysema.[12]

Infection

Air can be trapped under the skin in necrotizing infections such as gangrene, occurring as a late
sign in gas gangrene,[2] of which it is the hallmark sign. Subcutaneous emphysema is also
considered a hallmark of fournier gangrene.[27] Symptoms of subcutaneous emphysema can result
when infectious organisms produce gas by fermentation. When emphysema occurs due to
infection, signs that the infection is systemic, i.e. that it has spread beyond the initial location, are
also present.[9][22]

Pathophysiology
Air is able to travel to the soft tissues of the neck from the mediastinum and the retroperitoneum
(the space behind the abdominal cavity) because these areas are connected by fascial planes.[4]
From the punctured lungs or airways, the air travels up the perivascular sheaths and into the
mediastinum, from which it can enter the subcutaneous tissues.[18]
Spontaneous subcutaneous emphysema is thought to result from increased pressures in the lung
that cause alveoli to rupture.[5] In spontaneous subcutaneous emphysema, air travels from the
ruptured alveoli into the interstitium and along the blood vessels of the lung, into the
mediastinum and from there into the tissues of the neck or head.[5]

Diagnosis
Significant cases of subcutaneous emphysema are easy to diagnose because of the characteristic
signs of the condition.[1] In some cases, the signs are subtle, making diagnosis more difficult.[13]
Medical imaging is used to diagnose the condition or confirm a diagnosis made using clinical
signs. On a chest radiograph, subcutaneous emphysema may be seen as radiolucent striations in
the pattern expected from the pectoralis major muscle group. Air in the subcutaneous tissues may
interfere with radiography of the chest, potentially obscuring serious conditions such as
pneumothorax.[19] It can also and reduce the effectiveness of chest ultrasound.[28] On the other
hand, since subcutaneous emphysema may become apparent in chest X-rays before a
pneumothorax does, its presence may be used to infer that of the latter injury.[13] Subcutaneous
emphysema can also be seen in CT scans, with the air pockets appearing as dark areas. CT
scanning is so sensitive that it commonly makes it possible to find the exact spot from which air
is entering the soft tissues.[13] In 1994, M.T. Macklin and C.C. Macklin published further insights
into the pathophysiology of spontaneous Macklin's Syndrome occurring from a severe asthmatic
attack.
The presence of subcutaneous emphysema in a person who appears quite ill and febrile after bout
of vomiting followed by left chest pain is very suggestive of the diagnosis of Boerhaave's
syndrome which is a life threatening emergency caused by rupture of the distal esophagus.

Bubbles of air in the subcutaneous tissue (arrow) feel like mobile nodules that move
around easily.

A chest X-ray of a right sided pulmonary contusion associated with flail chest and
subcutaneous emphysema.

Subcutaneous air (arrows) can be seen as black areas on this pelvic CT scan.

Treatment
Subcutaneous emphysema is usually benign.[1] Most of the time, SCE itself does not need
treatment (though the conditions from which it results may); however, if the amount of air is
large, it can interfere with breathing and be uncomfortable.[29] It occasionally progresses to a state
"Massive Subcutaneous Emphysema" which is quite uncomfortable and requires surgical
drainage. When the amount of air pushed out of the airways or lung becomes massive, usually
due to positive pressure ventilation, the eyelids swell so much that the patient cannot see. Also
the pressure of the air may impede the blood flow to the areolae of the breast and skin of the
scrotum or labia. This can lead to necrosis of the skin in these areas. The latter are urgent
situations requiring rapid, adequate decompression.[30][31][32] Severe cases can compress the
trachea and do require treatment.[33]
In severe cases of subcutaneous emphysema, catheters can be placed in the subcutaneous tissue
to release the air.[1] Small cuts, or "blow holes", may be made in the skin to release the gas.[16]
When subcutaneous emphysema occurs due to pneumothorax, a chest tube is frequently used to
control the latter; this eliminates the source of the air entering the subcutaneous space.[2] If the
volume of subcutaneous air is increasing, it may be that the chest tube is not removing air rapidly
enough, so it may be replaced with a larger one.[8] Suction may also be applied to the tube to

remove air faster.[8] The progression of the condition can be monitored by marking the
boundaries with a special pencil for marking on skin.[33]
Since treatment usually involves dealing with the underlying condition, cases of spontaneous
subcutaneous emphysema may require nothing more than bed rest, medication to control pain,
and perhaps supplemental oxygen.[5] Breathing oxygen may help the body to absorb the
subcutaneous air more quickly.[10] Reassurance and observation are also part of treatment.[17]

Prognosis
Air in subcutaneous tissue does not usually pose a lethal threat;[4] small amounts of air are
reabsorbed by the body.[8] Once the pneumothorax or pneumomediastinum that causes the
subcutaneous emphysema is resolved, with or without medical intervention, the subcutaneous
emphysema will usually clear.[19] However, spontaneous subcutaneous emphysema can, in rare
cases, progress to a life-threatening condition,[5] and subcutaneous emphysema due to mechanical
ventilation may induce ventilatory failure.[26]

History
The first report of subcutaneous emphysema resulting from air in the mediastinum was made in
1850 in a patient who had been coughing violently.[5] In 1900, the first recorded case of
spontaneous subcutaneous emphysema was reported in a bugler for the Royal Marines who had
had a tooth extracted: playing the instrument had forced air through the hole where the tooth had
been and into the tissues of his face.[5] Since then, another case of spontaneous subcutaneous
emphysema was reported in a submariner for the US Navy who had had a root canal in the past;
the increased pressure in the submarine forced air through it and into his face. In recent years a
case was reported at the University Hospital of Wales of a young man who had been coughing
violently causing a rupture in the esophagus resulting in SE.[5] The cause of spontaneous
subcutaneous emphysema was clarified between 1939 and 1944 by Macklin, contributing to the
current understanding of the pathophysiology of the condition.[5]

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