Spot the Pneumothorax

Subcutaneous emphysema (SE) and pneumomediastinum are commonly associated with critically ill patients with blunt or penetrating trauma, in particular lower rib fractures. It however rarely needs urgent intervention, and routine use of chest tube tracheostomy or mediastinal drains is not recommended as the patients do not go on to develop a respiratory compromise. Our case is novel as it describes a case of subcutaneous emphysema with acute upper airway compromise and respiratory distress requiring urgent bilateral wide bore subcutaneous drains and thoracic drain insertion. The patient required a prolonged recovery period. This case serves to illustrate the technical difficulty in establishing a cause of subcutaneous emphysema, the limitations of standard imaging in identifying a pneumothorax in subcutaneous emphysema, and the value of prompt insertion of bilateral subcutaneous wide bore drains to buy precious time for definitive imaging and management.