Fillers A memorable patient

The inflating lady

BMJ 1998; 317 doi: (Published 31 October 1998) Cite this as: BMJ 1998;317:1230
  1. Solomon Almond, senior registrar in clinical pharmacology and therapeutics
  1. Liverpool

    Some four years ago, as a novice medical registrar, I was awoken at 3 00 am by a panic stricken senior house officer who told me that an elderly woman had been admitted to the accident and emergency department in anaphylactic shock, presumably from a dressing on a trivial back injury. The patient had had adrenaline, steroids, antihistamine, and nebulisers but remained ill. Of particular worry was her worsening facial and neck oedema, which I was told was endangering her airway.

    I was already half dressed as the conversation ended. I asked the senior house officer to inform the duty anaesthetist of our problem and left for the casualty department. The woman was indeed unwell. She was distressed and clearly very breathless. Strikingly, and of great concern, her face was swollen and her neck was perhaps double its natural circumference. The cardiac monitor showed her to be tachycardiac and a cursory examination revealed wheezes but little else.

    My first thought was for the airway. The anaesthetist came down and immediately shared my anguish. He began busying himself preparing the paraphernalia for intubation when the radiographers arrived to carry out a chest x ray examination. For a brief moment the anaesthetist and I debated the wisdom of doing such a procedure in a patient who was clearly in danger of closing her airway at any moment, but we decided to let it go ahead.

    As we grasped the patient by the shoulders to sit her forward for the x ray examination our hands seemed to sink in with a crunching feeling; at that moment a realisation of the diagnosis came in tandem to me and the anaesthetist on either side of her.

    The old lady had fallen before going to bed, injuring her back. A small dressing had been applied to an innocuous looking graze, but she had awoken in the early hours with facial swelling. I later learnt that she had been fine until powerful drugs had been administered in the resuscitation room. Her chest x ray film showed a rib fracture, a small pneumothorax, and gross surgical emphysema. Most of the air that was admitted into her thoracic cavity had collected between the lung and the chest wall. The traumatic nature of the pneumothorax, however, had facilitated the passage of air into the subcutaneous tissues—an unusual consequence of spontaneous pneumothoraces but not uncommon after injury. She made an uneventful recovery from her ordeal.

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