title: Management of significant and widespread, acute subcutaneous emphysema: should we manage surgically or conservatively?
abstract: BACKGROUND
  Subcutaneous emphysema of a limb after acute injury is classically associated with gas gangrene. Delayed management can result in amputation and death. Typically caused by a clostridial infection, patients are unwell, with rapidly spreading clinical signs, abnormal laboratory results, and cultures positive. There are reports of widespread subcutaneous emphysema of a limb in well-appearing patients, with blood parameters within normal limits; however, the optimum management of this type of case is unclear.
  
  
  OBJECTIVE
  Our objectives were to present 4 new cases of acute subcutaneous emphysema in well-appearing patients managed with early surgery, review the literature, and discuss the management decisions in cases of acute subcutaneous emphysema in clinically well patients.
  
  
  METHODS
  Here we present a case series of 4 patients, all with penetrating injuries to the upper limb resulting in widespread subcutaneous emphysema within 24 h of injury. Mean age was 33 years. All were fit and well, with the exception of one with type 1 diabetes, no cardiorespiratory compromise, and no significant derangement of laboratory investigations. X-ray studies showed widespread gas within the soft tissues. All were treated aggressively with immediate surgical fasciotomy of the upper limb, thorough debridement, and washout as required. Gram stains revealed pus cells (polymorphonuclear leucocytes) in all, but organisms in only one case (Gram-positive cocci and bacilli). Prolonged culture grew organisms in all. All patients had a second washout and closure plus 6 weeks of antibiotics. All survived and had fully functioning limbs. Why should an emergency physician be aware of this? We recommend having a low threshold for rapid referral to an appropriate surgical speciality, allowing prompt and radical surgical management of this type of presentation, even in the presence of a well patient.
authors.affiliation: Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, England.
authors.forename: Richard P
authors.initials: RP
authors.lastname: Jeavons
authors.affiliation: Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, England.
authors.forename: Daniel
authors.initials: D
authors.lastname: Dowen
authors.affiliation: Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle upon Tyne, England.
authors.forename: Paul R P
authors.initials: PR
authors.lastname: Rushton
authors.affiliation: Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, England.
authors.forename: Simon
authors.initials: S
authors.lastname: Chambers
authors.affiliation: Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, England.
authors.forename: Shaun
authors.initials: S
authors.lastname: O'Brien
mesh_terms: D000208:Acute Disease; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003646:Debridement; D000071938:Fasciotomy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D013352:Subcutaneous Emphysema / Q000000981:diagnostic imaging / Q000382:microbiology / Q000628:therapy*; D007507:Therapeutic Irrigation; D034941:Upper Extremity / Q000601:surgery; D014950:Wounds, Penetrating / Q000150:complications; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents
keywords: debridement; fasciotomy; necrotizing fasciitis; soft tissue infection; subcutaneous emphysema; surgical emphysema