Massive subcutaneous emphysema, bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoscrotum after multiple direct laryngoscopies: an autopsy case report

Abstract

Multiple endotracheal intubation (ETI) attempts increase the risk of airway-related adverse events. However, little is known about autopsy findings after severe ETI-related complications.We present the detailed pathological findings of a case with severe ETI-related complications. A 77-year-old obese male suffered cardiopulmonary arrest after choking at a rehabilitation facility.Spontaneous circulation returned after chest compressions and foreign-body removal. After multiple failed direct laryngoscopies, the patient was transferred to our hospital. He had massive subcutaneous emphysema, bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoscrotum on admission and died from hypoxic brain injury 15 hours later. Autopsy revealed severe oropharyngeal; laryngeal; and left lung lower lobe injury. The likely mechanisms of diffuse emphysema were: 1) oropharyngeal injury associated with multiple ETI attempts and excessive ventilation pressures and 2) left lung lower lobe injury associated with chest compressions and other resuscitative procedures. Multiple laryngoscopies can cause severe upper-airway injury, worsen respiratory status, and make ETI more difficulta vicious circle that can be prevented by limiting ETI attempts. This is particularly important in unfavorable environments, in which backup devices and personnel are not easily obtained. The pathological findings of our patient caution against repeated attempts at ETI during resuscitation.

A Comprehensive Review of Medical Imaging Equipment Used in Cadaveric Studies

“…Further complications, such as upper airway injury and worsening respiratory status, can arise if a laryngoscopy is improperly performed several times. Postmortem autopsies done with endoscopy, on patients with multiple failed intubation attempts and over-ventilation, show significantly more harm than those with a single successful intubation [ 33 ].…”

Unilateral blindness following superior laryngeal nerve block for awake tracheal intubation in a case of posterior cervical spine surgery

“…However, if not performed by an expert, SUPLANEB carries the risk of subcutaneous emphysema, pneumomediastinum, pneumothorax, hematoma formation, and laryngospasm. [ 15 ] In addition, the local anesthetic toxicity of SUPLANEB includes local neurologic complications including laryngeal anesthesia, dysphagia, and dysphonia (e.g., they usually recover within a few hours). [ 8 , 17 ] Rare central nervous system toxicity following SUPLANEB can include convulsions attributed to the accidental injection of local anesthetic directly into the carotid artery.…”

Pneumoscrotum: Value as an early diagnostic sign of tension pneumothorax in blunt thoracic trauma

“…The proposed mechanism of extrascrotal spread is via a patent processus vaginalis which can be present in up to 15%–30% of adults or through dissection through the pneumomediastinum, Scarpa's fascia in the abdominal wall, or retroperitoneal tissue down to the scrotal sac. [123456] This extrascrotal air is iatrogenic in 50% of cases from invasive procedures such as colonoscopies or secondary to either blunt or penetrating thoracoabdominal trauma. [456] Consideration of the differential diagnosis of an enlarging scrotum is therefore particularly important as pneumoscrotum can arise from extra-genital anatomic locations and misdiagnosis of these conditions can be potentially fatal.…”

“…The first incidence of pneumoscrotum was reported in 1912 following a nephrostomy, and in the following century, few cases have been reported in the literature with only 59 incidences documented between 1972 and 2013, with a variety of etiologies described including introduction of air within the pleural or abdominal cavities and local infections such as with Fournier's gangrene. [23]…”

“…Of these etiologies, the true incidence of pneumoscrotum secondary to blunt thoracic trauma and tension pneumothorax is unknown due to the scarcity of literature on the specific topic, and on our review, there are only a handful of reported cases of pneumoscrotum overall in the English literature. [12345678910111213141516] Given the precedence for this pathophysiology and the life-threatening etiologies, such as pneumoperitoneum or pneumothorax, the importance of finding a cause for a pneumoscrotum in the setting of trauma should not be overlooked. As we witnessed, this finding can lead to earlier diagnosis, but more importantly, timely, life-saving intervention.…”