Subcutaneous emphysema that looks like angioedema

[wilderness911]

Hello folks,

Just wanted to see if anyone else has encountered subcutaneous emphysema that migrated up to the face and looked like a nasty case of angioedema! Haven't seen this too often, but enough that I figured it would be worth raising the question. Subcutaneous emphysema is always one of my differentials now when I come across a notably edematous face!

 

[Carlos Danger]

Several times I've seen some pretty dramatic SC emphysema that involved the neck and face, but I can't say it ever looked like angioedema.

 

[harold1981]

Never seen it. However I do remember a nightshift when I was called to a hotel for a lady with severe swelling of the tongue. We couldn't find any other evidence of a systemic anafylactic reaction. The lady had been sleeping for a few hours and woke up with a funny feeling in her mouth. The angio edema was restricted to her tongue, no other surrounding tissue was involved, her sats were 99% and no stridor was to be heard. She was anxious though, and I was completely clueless on what was causing this extreme swelling locally, with no other signs or symptoms and nothing unusual in the history. We proceeded to treat the condition like an anafylactic reaction, with oxygen, adrenaline IM, clemastine IV and dexamethason IV, which kept her stable enough to maintain an airway. Later I learned that this was a case of macroglossia, based on angio edema, which is a rare side effect of lisinopril, a drug that she was taking at the time. The treatment was correct.

 

[Gurby]

My first pneumothorax, guy had massive subq emphysema of face. Coming out of nursing home, SOB for 2 hours, they thought it was allergic reaction and had been treating as such, wondering why he wasn't getting better... exam of chest shows subq emphysema of chest on one side as well. Hmmm I wonder if we should listen to lung sounds....

 

[NomadicMedic]

Yep. MVA, first responders thought he crashed his car because of a bee sting and jabbed him with an epi pen.

Had a pneumo and arrested shortly after I arrived.

 

[wilderness911]

Yeah; both of those cases mesh with what I have encountered. Initial responders mistook subcutaneous emphysema for anaphylaxis angioedema and jabbed them with some Epi. Makes me think we should do a better job educating folks about atypical presentations of subcutaneous emphysema, because missing a pneumo and treating for anaphylaxis instead is a great way to kill your patient. DE, I take it he did not come back?

And Gurby, you are absolutely right on the lung sounds. Any patient I get with angioedema gets lung sounds anyways to determine if there is any airway compromise, but I think that we need to have a high index of suspicion that a patient with apparent angioedema and SOB without exposure to an allergen may be suffering from a pneumo and not anaphylaxis at all. As you said, lung sounds should really make this a non-issue but it's just another case of not missing the zebra because it looks like a horse!

 

[Doczilla]

Were his lips and tongue swollen along with his face?

 

[Gurby]

Were his lips and tongue swollen along with his face?

My guy's lips and tongue were not swollen - only the rest of the face - which I suppose is a giveaway that you're dealing with subQ emphysema and not angioedema.

 

[harold1981]

Had a 12yo girl involved in a heads-on collission. She was deceased by the time we arrived, but she had indeed tremendeous swelling of one side of her face and jaw.

 

[E tank]

Air can track into the submucosa of the upper airway worsening any respiratory distress. Really mucks up the clinical picture.