- by NJNursing May 9, '07I had this one pt last week and this has been eating at me. The pt had a right sided chest tube. Suction was d/c'd that day and it was to gravity drainage. The tube was sutured in place. He slept throughout the night but at 5 am he had a 3rd dose of solu medrol which was started the day before. Our techs do hourly rounds on the pts and I will pop my head in to make sure that everyone is sleeping soundly or if they're awake see if there's a problem. He called about 6:15 saying that he was having some swelling of his face. I go in and sure enough his face is markedly swollen. He was having no problems breathing, no problems swallowing and no pain, but just some edema of the face and neck. I immediately call his attending (but it was his partner who was on-call)who said it was probably edema related to the solu-medrol. I explained what a change it was from 5 to 6:15. He said he'd see him first when he came in. I relayed all of this information back to the pt and reassessed the fact he was having no breathing/swallowing problems or pain but told him to call me if he was having any further changes or problems.
At shortly after 7 as I'm giving report to the next shift, the doctor comes out to the nurses station and says the pt has crepitus and he was going to call the pulmonary sugeon who put the chest tube in. He also calls his colleague who is the true attending. Myself and the oncoming nurse go in because frankly neither of us has ever seen crepitus and wanted to have a feel as did many on the floor. One seasoned nurse said that in 15 years she's never seen crepitus in a pt. I finish giving report going in to the pt to again reassess for any discomfort or difficulties in airway or swallowing noting that his right eye was beginning to swell which I relayed back to the oncoming nurse and document the whole series of events that had occurred.
I go in that night and look at the pt board and see he's not in my section, so I ask the CC why. She said that the family was very upset and felt I didn't do enough to help him out or didn't check on him enough through the night. He was checked on by someone hourly! I also found out that when the dr who visited him called the attending he was asked if the chest tube was connected to suction and he said yes. When the attending came in around 1pm and found it wasn't (because the thoracic surgeon d/c'd the suction the day before) he went through the roof and the pt suffered with the edmea of the crepitus from 5am until at least 1 when the suction was applied and the edema started to go down. The chest tube was repositioned and the surgeon went ballistic that he wasn't called first. However later that day (he was another nurse's pt) he had a relapse of the crepitus and quickly fixed. I had the weekend off and thought he was discharged and found he's on another floor. Not upgraded, not downgraded but just another med/surg floor. All of a sudden we all had to attend an in-service on chest tubes and crepitus and they referenced that pt (not knowing it was me who had him that first night).
A friend of mine told me to make sure my insurance is paid up in case he decides to sue. Now I'm all paranoid that I did something wrong. I'd never seen crepitus. Many of the other more seasoned nurses have never seen crepitus. Even the educator who's been a nurse for 30 years says shes only seen it twice. My first thought was allergic reaction (but to solu-medrol?) and wasn't really buying that it was swelling from the med, but I would not have thought crepitus. What do y'all think?
- May 9, '07 by NREMT-P/RNI am a bit confused.
I always associated crepitus as the sound/feeling of bone ends moving against each other from fracture. Crepitus was apparent on palp to the scapular area as the bone was fractured.
I wonder if what you are referencing is subcutaneous air in the tissues. I usually reference this as a "rice krispie" type crackling on palp.
I would imagine that IF subQ air was the case and the respiratory status remained free of genuine compromise, it is well - what it is. A limited complication.
I have seen probably a dozen or so cases of subQ emphysema - usually associated with massive injury to the airway or associated structures. It is not uncommon after new trach placement. The few cases that I recall of limited subQ air were NOT associated with any permanent damages. Specific treatment usually focuses on resolution of the underlying cause - I've also seen some freaky attempts to relieve it (by needle decompression, no less) - but it usually resolves over time.
I think you observed/assessed/reported your patient in an a timely, professional manner. Don't let the family get to you - I would just mark it up to a personal decision from the family.
Don't sweat this too much. Report as required by your facility. Discus with your clinical manager/risk manager. Make sure your documentation is top rate and now RELAX.
Just keep on - and I'm willing to bet that you will never forget this, keep in mind that there was no tragic outcome - so it is a lesson learned. That is all.
Focus on being the wonderful nurse that you are - and now you are a wee bit wiser too! Sounds like you did a good job for the patient to me.
- May 9, '07 by NRSKarenRNworking respirastory unit, seen crepatius = subcutaneous emphysema develop several times---hallmark sign is increasing edema chest> scapula> neck to face with rice crispy feeling and crackling when skin palpated. (or like popping those plastic air bubbles)
docs should have picked up on it in am. re-establishing suction to chest tube should have been done as soon as discovered too.
what a lesson to learn--both patient & nursing staff. chest tube inservice definately needed.
medlineplus medical encyclopedia: subcutaneous emphysema
subcutaneous emphysema occurs when air gets into tissues under the skin covering the chest wall or neck. this can happen due to stabbing, gun shot wounds, ...
progressive subcutaneous emphysema and respiratory arrest
subcutaneous emphysema is often seen after thoracic surgical procedures. in most cases it is due to a leak from the lung parenchyma and is self-limiting, ...
simple construction of a subcutaneous catheter for treatment of ...
subcutaneous emphysema often presents a management dilemma. rarely, subcutaneous emphysema has pathophysiologic consequences. more often, it is extremely ...
eliminate the air of mystery from chest tubes nursing - find articles
go with the flow of chest tube therapy
25- what is subcutaneous emphysema, and what does it have to do with chest tubes? please keep the following in mind as you read this faq: the information
Last edit by NRSKarenRN on May 9, '07
- May 9, '07 by NJNursingI guess that yes, the new PC term is subQ emphysemia, but i learned it as crepitus and you're right it could also mean the term with bones grinding against each other. One of those dual termed words.
I guess I'm just paranoid because I'm still in my first year of nursing and while I have been trained really well, I just don't want inexperience to cause me to make a mistake. The clinical coordinator told me not to worry about it that it was mostly a series of misQ's between the doctors. The guy's swelling is gone now, his chest tube has since been removed, but still. Thanks for the reassurance. I just wanted to pass it by some experienced 'worldly' nurses. :-)
- May 9, '07 by TazziRNCrepitus is not something easily recognized if you've never actually seen it before, so I'm not surprised you didn't realize what it was. It's not your fault the on-call doc screwed up his report to the actual attending, or that the surgeon wasn't called sooner. Definitely inservice is needed but I don't think you did anything horribly wrong.
- May 10, '07 by NRSKarenRNPS, your notes should support your actions...do aides record hourly rounding on charts? Fact that doc saw him in AM helps share responsibility for pts care.
Lesson learned, if it doesn't seem right, go up the chain of physician command. Inservice will help with care of Chest tubes. Lessons learned from this "nursing adventure" will stay with you forever. Guess who will be the chest tube guru now YOU!
- May 10, '07 by NorthpoleRNMy understanding of crepitus in this pt is that he had crackles in the lungs due to all the fluid accumulation. Did anyone listen to his lungs? I don't believe you are at fault. You did not D'C the suction. You simply followed the orders.
- May 10, '07 by Angie O'Plasty, RNI've had patients with crepitus before. The areas were in the vicinity of the chest tube and were small and self-limiting.
I appreciate you posting this and the information that this case generated. I really had no idea how bad this problem could get.
- May 10, '07 by BBFRNI'm with Karen. Have seen crepitus as described several times with chest tubes. Think of it as air trapped under the skin- you have air leaking out, so if it's not self-contained to a small area like in the OP's pt, that's why you put the pt back to suction ASAP. Always palpate edemaous sites, so you can feel for crepitus. You can have crepitus with fractures as well, but it's usually around bursa, skull fx's (think sinuses), or with rib fx's.
- May 10, '07 by jmgrn65Quote from NorthpoleRNMy understanding of crepitus in this pt is that he had crackles in the lungs due to all the fluid accumulation. Did anyone listen to his lungs? I don't believe you are at fault. You did not D'C the suction. You simply followed the orders.
crepitus=subq emphesyma is air under the skin, which has escaped from the lung (air Leak). Listening to his lungs is always good but wouldn't have changed the situation, usually the lungs sound aren't effected.