The article was consulted professionally by Master, Dr Phan Ngoc Math – Emergency Resuscitation Doctor – Emergency Resuscitation Department – Share99 Da Nang International Hospital. The doctor has extensive experience in resuscitation and emergency treatment.
1. General overview
Underu skin gas overflow (TKDD) is a phenomenon that arises or penetrates the air into the under-skin layer of the skin. The skin is composed of the epidermis and dermis, with the underdicular tissue located under the dermis. However, the development of gas overflow under the skin may show that air is occupying another area deeper in the body that is not visible to the naked eye.
Gas spills into the body's cavities and other voids can cause medias center gas spills, abdominal gas overflows, and pleural gas overflows. The air moves from these areas according to the pressure difference between the alveoli and the interstitial interval around the blood vessels, spreading to the head, neck, chest and abdomen by connecting the anatomy and conjunctivitis planes. Air will accumulate in areas under the skin with the least tension until the pressure increases enough to divide along other planes, causing a spread under the skin and can cause respiratory and cardiovascular distress.
Mechanically, air or gas enters the dermis leading to a gas spill under the skin. The skin from her, the mediasm and the peritoneal cavity are connected by fascialplanes and the air is allowed to follow the plane itself, and then move from cavity to cavity.
Air can track the perivascular sheaths, into the medias center and thereby enter the tissue under the skin, if the lungs are punctured (whether in the pleura or organ pleura). Similarly, excessive pressure in the lungs may have ruptured the alveoli in the pressure gas injury and air spilled into the underside of the organ pleura, up to the pulmonary navel, along the pneumothorax and into the neck.
In chest injuries, the presence of a gas overflow under the skin usually represents a serious thoracic lesion associated with gas-containing structures in the chest.
TKDD can be caused by surgery, injury, infection or sedation. Injuries to the chest cavity, sinuses, facial bones, pressure injuries, perforation of the intestines or rupture of the pulmonary gas cocoon, these are some common causes.
Causes of medical treatment such as malfunctions associated with ventilators, Valsalva procedures increase thoracic pressure and airway injuries. Air can enter the underpeal cavities due to minor mucosal lesions in the in the uryn system or in theryn membrane during in-administration due to injury, excessive effusion of the ineocular effusion (ET), or increased airway pressure when the bar is closed. Damage to the fulness of the fulness during the cathetro of the stomach can also create points of communication with the air path.
Air can enter the subaldible tissue through the soft tissues of the neck during the opening of the esophagus, through the chest wall during shoulder articulscopy, through the 3 3 veins due to labor accidents, through the intestines or perforation of the esophagus without lung injury, or through the thoracic opening or in the procedure of central vein access procedures , or transpulsive or trans-bronchial lung biopcopy.
TKDD has also been observed after the air escapes during endoscopy and through the female genitals when examining the pelvic area, dosing, post-birth exercise …
The development of underu skin-soaked gases is believed to be due to the following mechanisms:
- Top pleural lesions allow air to enter the pleura and tissue under the skin
- Air from the alveoli spreads into the endotline and the pulmonary navel into the weight layer (pleura wall) in the thoracic cavity.
- Mediasceral air spreads between the neck organs and other connective tissue planes
- Air originating from the outside
- Local gas creation due to infection, namely necrotic infections
The most common symptom is a swollen/ fishy explosion when touching the suspected skin of TKDD, depending on the disease, there may be pain, balloons moving or deformation of the bulging type in the abdomen, chest, neck and face …
Eyelash edema that causes visual effects and vocal changes or wheezing due to vocal cord pressing may also appear
For patients with widespread TKDD, hemolysis or respiratory effects may occur, which is why it is necessary to investigate the cause of hypothalema in each patient.
On X-rays, there are non-continuous areas (increased brightness), often smooth ridges appear on the outer edge of the chest and abdominal wall. On chest X-rays, gas bands along the chest muscles are visible, resembling a cardokgo leaf.
A com computer cirography film (CT Scan) will show that the black bags in the underpant layer are a sign of gas. CT may be sensitive enough to identify the source of the injury that causes TKDD without seeing it on inclined X-rays or before the latter. If tKDD in the neck or face appears during in-administration, then a laparoscopy of the nasopharynx should be performed before inngisophageion to assess imminent airway damage or pharyngeal gas overflow. In addition, if airway damage is suspected due to in-administration, bronchoscopy can help determine the location of the pneumatic lesion.
Ultrasound, although air acts as a negative barrier when using ultrasound, TKDD can manifest it by scattered res tangents. By placing an ultrasound probe on the skin without gas overflow, pneumothorax can be diagnosed due to the lack of a "sliding lung" and "A line" marks with a sensitivity of 95%
Treatment of the basic cause or motivated factor should be considered first as it often leads to a gradual resolution of TKDD. For mild cases that do not cause significant discomfort to the patient, just follow up. In patients who feel constant discomfort or need a quick resolution, high concentration oxygen is a common treatment, which allows to eject nitrogen and diffuse gas particles in patients while simultaneously suffering from pneumothorax and/or medias mediasm gas overflow.
During in-administration, injuries may occur to the post-inomatic building, causing a laceration to the mucous membranes. It may be necessary to open the ina muster to ignore the tear and prevent additional underp dermatitis or other complications. When there is mucosal tearing, experienced broad-spectrum antibiotics can also be beneficial to prevent the development of mediascitis. For patients with mechanical ventilators, reducing VT, PEEP and minimizing bronchospasm and gas traps can prevent gas overflow from progressing and promote reabsorption…
In patients with widespread underuocular gas, there are reports that 2cm incisions on the sides can reduce the further spread of gas under the skin. In one case report, a patient with widespread TKDD after opening the drained chest was successfully treated with a drain placed shallowly under the skin to the chest balance layer with low suction pressure. Most experts reserve invasive therapy for cases of increased airway compression or cardiovascular damage.
7. Differentive diagnosis
In some limited case reports, TKDD has been mistaken for allergic reactions and anesthor edema after the patient showed shortness of breath and swelling of the face. Examination can help differentiate between these two types because TKDD is not on the lips. While non-life-threatening non-life-threatening TKDD may be a clue to other life-threatening conditions that need to be checked and excluded including esophageal rupture, pneumothorax, perforation of the tradge/intestine/diaphragm, and necrotic infections. It is important that after ins tradation, it is necessary not only to think about the pressure injury caused by the alveolar lesion that is the source of TKDD, but also to check for the tram tears caused by in-administration.
Most of the underfloin gas is non-fatal and self-limiting. Even in the case of positive pressure ventilators, TKDD is considered benign and does not require venation adjustment. However, in the event that the gas expands quickly and more can be life-threatening. Massive TKDD can cause cavity compression syndrome, which prevents the expansion of the chest wall, compression of the intural cavity and tissue necrosis. In these frightening complications without intervention, respiratory and cardiovascular inhibitions may occur. The increase in gas volume will also be accelerated with the use of nitrogen oxides and positive pressure oxides, which quickly worsen the dosing and can contribute to increased incidence and mortality.
Wide blue air overflow in the underped tissues can prevent chest dilation, difficulty reaching the appropriate volume of informedity, leading to loss of peace, respiratory failure and the threat of cardiac arrest. Air spilling into the neck can cause difficulty swallowing and pinching or causing airway closures. When supporting ventilation, if the appropriate volume of ventilation cannot be achieved, it leads to peak pressure and causes damage caused by pressure or widespread pleural gas overflow. If TKDD interferes with the way out to the chest, it can prevent adequate airflow, reduce the burden of the heart and lead to poor brain perfusence. TKDD in the genitals can disrupt the delicate blood vessels supplied to these areas, causing skin necrosis. In patients with an pacemaker, it can cause dysfunction of the device due to gas retention in the impulse unit.
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