Immediate Management of Subcutaneous Emphysema After Central Line Insertion

Critical Initial Assessment and Stabilization

The American Society of Anesthesiologists recommends immediate assessment for airway compromise and tracheal injury, administering high-flow oxygen, positioning the patient head-up, and preparing for emergency surgical airway if signs of respiratory distress develop, while simultaneously initiating aggressive medical management of impending thyroid storm 1, 2
Administer supplemental high-flow oxygen immediately and position the patient in a head-up position to optimize airway patency and reduce airway edema, as recommended by the American College of Surgeons 1, 2
Assess for signs of airway compromise using the DESATS criteria: Difficulty swallowing/discomfort, increase in Early warning score, Swelling, Anxiety/agitation, Tachypnea/difficulty breathing, and Stridor, as suggested by the American Heart Association 3, 2
Ensure portable lighting is available for adequate visualization of the neck, as recommended by the American Society of Anesthesiologists 1, 2
Immediately call for senior anesthesia and surgical support if any signs of airway compromise are present, as advised by the American College of Emergency Physicians 1, 2

The British Journal of Anaesthesia suggests that subcutaneous emphysema following central line insertion may indicate pneumothorax with tracking of air into neck tissues 4
Obtain urgent chest X-ray to evaluate for pneumothorax and mediastinal air, as recommended by the American College of Radiology 2
Perform flexible endoscopic laryngeal assessment by an experienced operator to evaluate for tracheal injury and airway patency, as suggested by the American Academy of Otolaryngology 1, 2

If signs of airway compromise are present, immediately notify senior anesthetist and prepare for emergency airway intervention, as advised by the American Society of Anesthesiologists 1, 2
Use videolaryngoscopy at first intubation attempt to maximize success, as recommended by the American Heart Association 2
Limit intubation attempts—multiple attempts worsen outcomes, as suggested by the American College of Surgeons 2
If cannot intubate, cannot oxygenate (CICO) situation develops, proceed immediately to scalpel cricothyroidotomy, as recommended by the British Journal of Anaesthesia 4, 5

The British Journal of Anaesthesia recommends maximum neck extension (if no cervical spine concerns) during scalpel cricothyroidotomy 4
Perform horizontal incision with wide scalpel blade (size 10 or 20) through cricothyroid membrane, as suggested by the British Journal of Anaesthesia 5
Insert bougie as guide for 5.0-6.0 mm cuffed tracheal tube, as recommended by the British Journal of Anaesthesia 4, 5

If tracheal rupture is identified, surgical exploration and primary repair is required, as advised by the American College of Surgeons 2
Maintain airway with endotracheal tube positioned distal to injury if possible, as recommended by the American Society of Anesthesiologists 2
Administer broad-spectrum antibiotics to prevent mediastinitis, as suggested by the American Heart Association 2

Transfer to level 2 or 3 care for close postoperative observation, as recommended by the American College of Emergency Physicians 2
Maintain head-up positioning and avoid unnecessary positive fluid balances to reduce airway edema, as advised by the American Society of Anesthesiologists 2
Perform serial chest X-rays to monitor pneumothorax or pneumomediastinum progression, as suggested by the American College of Radiology 2