ER Diaries : The Crepitus

Hey all

9pm . Chill ER . A 53 year old male Diabetic ,CAD , Stage 4 CKD on hemodialysis who had 2 fingers amputated earlier came complains of swollen lower limbs with non healing wound which developed gradually following rupture of a bleb. The last serum creatinine was 5 mg/dl. On local examination , the wound was foul smelling with pus oozing out. 

We examined the wound and called up the consultant surgeon to come and have a look. He walked in examined the wound advised color Doppler of lower limbs . Nephrology referral and was about to leave when a 35 year old lady bumped into him.

Who is she? He asked. 

Umm... Sir , I don’t know who she is sir . I didnot take her history yet.

Let me see . He turned back.

A wooden stool had apparently fallen on her trunk leaving the right side of her chest wall in pain.  There were no external injuries. The area was tender . The only complain she had was pain. She was hemodynamically stable n coherent with her surroundings. 

The surgeon compressed her ribs . Turned back to me and asked , Doctor what do you think I am looking for ?  Crepitus? I asked. 

Ok? And what for ? What am I trying to rule out he asked.

Rib fracture? Internal injuries?

Haha! He laughed .

What’s your name? 

Wajeeha , Sir .

Yeah so Dr. Wajeeha ... I was looking for one crepitus , you reminded me of another he said . Now tell me all the crepts you know.

Panic mode was on. My brain I don’t know died of short circuit . O hello. You can’t leave just like that , I yelled in my head virtually kicking my brain.

Sir , the one fracture one , the auscultation one?

Haha! Doctor you reminded me of the third crept! But mind you I am surgeon I am least bothered about the third crept . I don’t carry a stethoscope along . I clinically look for another crepitus.

When did you pass out ? 

April , Sir.

Now you can’t be so out of place with your subject. Take as much time as you want . I am not leaving the ER until you tell me that.

Nothing working. O hello brain , get some glucose from glycogenolysis and get up! Izzat ki baat (LOL!)

See , I am a poor man. I don’t do eFAST and all for blunt injuries . I do my clinical thing and advise investigations.

Let me give you a hint . The injury would slip from subcutaneous tissue from site of injury till the neck . Compress the structures like vessels. Come on ! Enough hints given.

Honestly , an eye won’t  see what a mind doesn’t know and mind won’t recall what it has never assessed . 

Okay doc! Tell me the structures that will possibly be injured if there is trauma on right side of chest wall.

The muscle , the rib fracture , the pleural damage hemothorax , tension pneumothorax may be?

Tension pneumothorax with blunt trauma?

Umm... no no pneumothorax !

What more?

Liver injury ?

Yeah ! How do you assess it? What do you look for?

Tenderness ? Signs of internal bleed?

And? 

Hello calling brain ! The organ you’re trying to reach is not available at the moment . Please try after sometime! Aaaah! Screwed man!

Pallor , icterus , hypotension Doctor! Signs of peritonitis ! Acute abdomen! You ER people you only assess ECGs for that little heart . You have bulk of viscera down there. Read about it . Don’t miss out !

And the third crepitus . The crepitus I was looking for is the one for subcutaneous emphysema . You need to assess it clinically before you get radiological intervention done.

At the end of grilling session he laughed and said . Now you’ll instruct the nursing staff to prevent me from entering the ER! 

Chest trauma, a major cause of subcutaneous emphysema, can cause air to enter the skin of the chest wall from the neck or lung. 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 .

Subcutaneous emphysema has a characteristic crackling feel to the touch, a sensation that has been described as similar to touching Tissue paper ,this sensation of air under the skin is known as subcutaneous crepitation.

Subcutaneous emphysema is usually benign. Most of the time, SCE itself does not need treatment.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. 

Severe cases can compress the trachea and do require treatment.

I really wished there be more of such grilling sessions. My cranium still seemed like an empty box . No brain in near sight .

So far so much 

Bye!