(P50) An Inflated Sense of Self: Extensive Subcutaneous Emphysema Secondary to Intentional Subcutaneous Air Injection

Chief Complaint : A 40-year-old male presents with shortness of breath, chest pain, abdominal pain, and abdominal distention after intentionally injecting air into his abdomen.

History of Present Illness : A 40-year-old male presented to the emergency department (ED) with shortness of breath, pain in his chest and abdomen, and abdominal distention after he injected air into his umbilicus with an air compressor. The patient has a history of schizophrenia and bipolar disorder, and states he was having intrusive thoughts to fill his body up with air. He placed a needle into his umbilicus, turned on an air pump, and inflated his abdomen until he noted blood from his umbilicus and swelling in his lower face. Though he was unable to quantify how much air was injected, the patient subjectively states “a lot”. Shortly after cessation with the air pump, the patient developed significant chest discomfort and shortness of breath. He also noted diffuse swelling of his abdomen as well as his chest, neck, and lower face.

Pertinent Physical Exam: The patient was hemodynamically stable with vital signs all within normal ranges. His face had notable symmetric swelling. His airway was patent, trachea was midline, and voice was high-pitched. Heart sounds were slightly muffled, and anterior lung sounds were symmetrically muffled though posterior lung sounds were clear. Abdominal exam revealed a moderately distended and firm abdomen with no tenderness or signs of peritonitis. Dried blood was noted near the umbilicus with small puncture wounds also appreciated. Skin exam revealed diffuse crepitus in the abdomen, chest, neck, and face extending from the chin to the periorbital area.

Pertinent Laboratory Data: Blood work performed included a complete blood count with differential, comprehensive metabolic panel, lipase, and troponin. A white blood cell count of 14.3 was noted, and the remaining bloodwork was within normal limits. The EKG showed low voltage with no ischemic changes. Imaging included a CT soft tissue neck as well as CT scans of the thorax and abdomen/pelvis. The CT scans showed marked, diffuse subcutaneous emphysema extending from the pelvis up through the periorbital bones. Pneumopericardium and significant pneumomediastinum were also visualized. A small amount of free intraperitoneal air was also noted.

Case Discussion: Throughout the patient’s ED course, he remained hemodynamically stable. After the initial evaluation was complete and imaging obtained, consults were placed to thoracic, cardiothoracic, and general surgery given the multiple system findings. Given there was no sign of esophageal perforation, cardiac tamponade, or any other acute surgical process, no emergent surgical interventions were warranted. The patient was admitted for observation and started on supplemental oxygen and empiric antibiotics. The patient was hospitalized for 4 days and remained stable; his symptoms improved, and he was discharged. Follow up imaging seven months later revealed marked interval resolution of subcutaneous and retroperitoneal air.

This unique case highlights a mechanism for extensive subcutaneous emphysema that is rarely described in current medical literature. Cases of self-induced subcutaneous emphysema are sparsely reported, and we have not found any secondary to this mechanism within the literature.

While some cases of subcutaneous emphysema do well with minimal interventions, the potential for significant morbidity and mortality does exist. Cases of subcutaneous air extravasation into the pericardium and mediastinum have been reported to cause life threatening sequelae. Subcutaneous emphysema may lead to pneumothorax, esophageal perforation, and pneumopericardium leading to cardiac tamponade. As such, cases of subcutaneous emphysema must be risk stratified and treated on an individual basis.

Management for uncomplicated subcutaneous emphysema includes supportive care. There has been at least one case reported that suggests 100% oxygen administration accelerates the resolution of symptoms. Hyperbaric oxygen therapy has also been utilized in the treatment of subcutaneous emphysema. Antibiotic treatment should be considered if there is concern for infectious etiologies or skin/soft tissue injuries. Consultation with appropriate surgical services should be considered, especially given the potential for life-threatening complications.

References and Acknowledgements (Optional): 1-Goudarzi, Mahmoud, and Jafar Navabi. "Self-induced subcutaneous facial emphysema in a prisoner: Report of a case." Ear, Nose & Throat Journal 90.6 (2011): E5-E6.

2-GERSHWIN, M. ERIC, JAMES K. GUDE, and JOHN PETRALLI. "Factitious subcutaneous emphysema." Annals of internal medicine 75.4 (1971): 585-587.

3- Meron, Giora, Karin Tobler, and Istepan Kurkciyan. "Self-induced subcutaneous emphysema and pneumomediastinum." Chest 122.1 (2002): 386.

4- Trujillo, Maximo H., Carlos F. Fragachan, and Francisco Tortoledo. "Cardiac tamponade due to pneumopericardium." Cardiology 105.1 (2006): 34-36.

5-Cavuslu, Saban, et al. "A case of recurrent subcutaneous emphysema as a complication of endotracheal intubation." Ear, nose & throat journal 83.7 (2004): 485-488.

6- Patel, Anshul, Branko Kesler, and Robert A. Wise. "Persistent pneumomediastinum in interstitial fibrosis associated with rheumatoid arthritis." Chest 117.6 (2000): 1809-1813.