- Email: [email protected]
Subcutaneous emphysema
Because of the relative safety and efficacy of Xylocaine jelly as a topical anesthetic, I recommend its use when cleansing s k i n abrasions in the emergency d e p a r t m e n t .
E. C. Mojares, MD Director of Emergency Medicine Overlook Hospital Summit, New Jersey
REFERENCES 1. Haines JS, Grabstald H: Xylocaine: a new topical anesthetic in urology. J Urol 62:901-902, 1949. 2. Nesbitt TE, Baum WC: Xylocaine gel, a new topical anesthetic agent. University of Michigan Medical Bulletin 18:157-159, 1952. 3. Persky L, Davis HS: Xylocaine as a topical anesthetic in urology. J Urol 70:552-554, 1953. 4. Webb EA, Smith BA, Price WE: Xyloeaine jelly for topical urethral anesthesia. Minn Med 39:417, 1956.
Subcutaneous Emphysema To the Editor: A recent addition to the multiple origins of s u b c u t a n e ous e m p h y s e m a 1 was reported by Stauffer and Petty. 2 They described a case of perforated pyriform sinus due to resuscitative i n t u b a t i o n . The i n j u r y has been related to the h u r r i e d l y performed procedure, as in an e m e r g e n c y setting, or by inexperienced personnel. I n t u b a t i o n t r a u m a to t h e p h a r y n x w i t h p h a r y n goesophageal perforation had been reported by Wolff, 3 who underscored the fact that more such complications will be seen as c a r d i o p u l m o n a r y r e s u s c i t a t i o n is performed with i n c r e a s i n g frequency. With the use of the esophageal o b t u r a t o r a i r w a y - - its p r o v e n safety a n d o p t i o n to e n d o t r a c h e a l i n t u b a t i o n w a s d e s c r i b e d by DonMichael 4 - - such complications could be avoided by paramedics inexperienced with the endotracheal route.
Donald Forester, MD Emergency Unit Director Albert Einstein Medical Center Philadelphia, Pennsylvania
Author's Reply Certainly, s u b c u t a n e o u s e m p h y s e m a (SCE) associated with r e n t s in the respiratory tract and e x t r a - a b d o m i n a l g a s t r o i n t e s t i n a l tract m a y occur with endotracheal i n t u -
76/430
bation, esophageal tomy.
obturator insertion, and tracheos,
D u r i n g a t t e m p t s at endotracheal i n t u b a t i o n , especially with faulty technique, inexperienced personnel, or in a~ e m e r g e n c y roadside setting, m a n y complications have been described. R e t r o p h a r y n g e a l dissection by the lary~. goscope or e n d o t r a c h e a l t u b e , p e r f o r a t i o n of the esophagus, p h a r y n x , or larynx, a n d lacerations of the p h a r y n x or larynx, all may cause air to escape into the tissues of the neck r e s u l t i n g in SCE.3, ~ Perforation of the pyriform s i n u s is a r a r e r cause. 2 These complications have also b e e n reported in controlled o p e r a t i n g roola situations.S, 7 E s o p h a g e a l p e r f o r a t i o n f o l l o w i n g t h e use of the esophageal o b t u r a t o r airway has been described J, s This may be associated with cervical SCE. The presence of cervical SCE is a common finding after tracheostomy. 5 With extensive dissection of pretracheal fascia d u r i n g the procedure, expiratory air may be forced around the trachesostomy tube into the tissue planes of the neck. 5 I n i t i a l scientific evidence does not appear to verify the s/tfety of the esophageal o b t u r a t o r a i r w a y J However, as indicated by Don Michael, 4 the different methods of acute ai,~way m a n a g e m e n t in regards to complications, success rates, cost/benefit ratio, etc, r e q u i r e f u r t h e r scientific study before definitive s t a t e m e n t s can be made.
Richard M. Nowak, MD Michael C. Tomlanovich, MD Division of Emergency Medicine Henry Ford Hospital, Detroit
REFERENCES 1. Nowak RM, Tomlanovich MC: Subcutaneous emphysema. JACEP 6:269-272, 1977. 2. Stauffer JL, Petty TL: Accidental intubation of the pyriform sinus. JAMA 237:2324-2325, 1977. 3. Wolff AP, Kuhn FA, Ogura JH: Pharyngeal-esophageal perforations associated with rapid oral endotracheal intubation. Ann Otol Rinol Laryngol 81:258-261, 1972. 4. DonMichael TA: Options for emergency management of the airway. JACEP 6:279, 1977. 5. Applebaum E, Bruce D: Tracheal lntubation. Philadelphia, W B Saunders Co., 1976. 6. Thompson D, Read R: Rupture of the trachea following endotracheal intubation. JAMA 204:137-139, 1968. ' '.' 7. Don Michael T, Archer G, Schofferman J: EsOphageal obturator airway - - a new adjunct in emergency airway management (abstract). Am J Cardiol 39:259, 1977. " 8. Pilcher D, DeMeules J: Esophageal perforation following use of esophageal airway. Chest 69:377-380, 1976.
6i9 (Sept) 1977J ~ P
E. C. Mojares, MD Director of Emergency Medicine Overlook Hospital Summit, New Jersey
REFERENCES 1. Haines JS, Grabstald H: Xylocaine: a new topical anesthetic in urology. J Urol 62:901-902, 1949. 2. Nesbitt TE, Baum WC: Xylocaine gel, a new topical anesthetic agent. University of Michigan Medical Bulletin 18:157-159, 1952. 3. Persky L, Davis HS: Xylocaine as a topical anesthetic in urology. J Urol 70:552-554, 1953. 4. Webb EA, Smith BA, Price WE: Xyloeaine jelly for topical urethral anesthesia. Minn Med 39:417, 1956.
Subcutaneous Emphysema To the Editor: A recent addition to the multiple origins of s u b c u t a n e ous e m p h y s e m a 1 was reported by Stauffer and Petty. 2 They described a case of perforated pyriform sinus due to resuscitative i n t u b a t i o n . The i n j u r y has been related to the h u r r i e d l y performed procedure, as in an e m e r g e n c y setting, or by inexperienced personnel. I n t u b a t i o n t r a u m a to t h e p h a r y n x w i t h p h a r y n goesophageal perforation had been reported by Wolff, 3 who underscored the fact that more such complications will be seen as c a r d i o p u l m o n a r y r e s u s c i t a t i o n is performed with i n c r e a s i n g frequency. With the use of the esophageal o b t u r a t o r a i r w a y - - its p r o v e n safety a n d o p t i o n to e n d o t r a c h e a l i n t u b a t i o n w a s d e s c r i b e d by DonMichael 4 - - such complications could be avoided by paramedics inexperienced with the endotracheal route.
Donald Forester, MD Emergency Unit Director Albert Einstein Medical Center Philadelphia, Pennsylvania
Author's Reply Certainly, s u b c u t a n e o u s e m p h y s e m a (SCE) associated with r e n t s in the respiratory tract and e x t r a - a b d o m i n a l g a s t r o i n t e s t i n a l tract m a y occur with endotracheal i n t u -
76/430
bation, esophageal tomy.
obturator insertion, and tracheos,
D u r i n g a t t e m p t s at endotracheal i n t u b a t i o n , especially with faulty technique, inexperienced personnel, or in a~ e m e r g e n c y roadside setting, m a n y complications have been described. R e t r o p h a r y n g e a l dissection by the lary~. goscope or e n d o t r a c h e a l t u b e , p e r f o r a t i o n of the esophagus, p h a r y n x , or larynx, a n d lacerations of the p h a r y n x or larynx, all may cause air to escape into the tissues of the neck r e s u l t i n g in SCE.3, ~ Perforation of the pyriform s i n u s is a r a r e r cause. 2 These complications have also b e e n reported in controlled o p e r a t i n g roola situations.S, 7 E s o p h a g e a l p e r f o r a t i o n f o l l o w i n g t h e use of the esophageal o b t u r a t o r airway has been described J, s This may be associated with cervical SCE. The presence of cervical SCE is a common finding after tracheostomy. 5 With extensive dissection of pretracheal fascia d u r i n g the procedure, expiratory air may be forced around the trachesostomy tube into the tissue planes of the neck. 5 I n i t i a l scientific evidence does not appear to verify the s/tfety of the esophageal o b t u r a t o r a i r w a y J However, as indicated by Don Michael, 4 the different methods of acute ai,~way m a n a g e m e n t in regards to complications, success rates, cost/benefit ratio, etc, r e q u i r e f u r t h e r scientific study before definitive s t a t e m e n t s can be made.
Richard M. Nowak, MD Michael C. Tomlanovich, MD Division of Emergency Medicine Henry Ford Hospital, Detroit
REFERENCES 1. Nowak RM, Tomlanovich MC: Subcutaneous emphysema. JACEP 6:269-272, 1977. 2. Stauffer JL, Petty TL: Accidental intubation of the pyriform sinus. JAMA 237:2324-2325, 1977. 3. Wolff AP, Kuhn FA, Ogura JH: Pharyngeal-esophageal perforations associated with rapid oral endotracheal intubation. Ann Otol Rinol Laryngol 81:258-261, 1972. 4. DonMichael TA: Options for emergency management of the airway. JACEP 6:279, 1977. 5. Applebaum E, Bruce D: Tracheal lntubation. Philadelphia, W B Saunders Co., 1976. 6. Thompson D, Read R: Rupture of the trachea following endotracheal intubation. JAMA 204:137-139, 1968. ' '.' 7. Don Michael T, Archer G, Schofferman J: EsOphageal obturator airway - - a new adjunct in emergency airway management (abstract). Am J Cardiol 39:259, 1977. " 8. Pilcher D, DeMeules J: Esophageal perforation following use of esophageal airway. Chest 69:377-380, 1976.
6i9 (Sept) 1977J ~ P