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Lack of efficacy: case report A 52-year-old woman exhibited lack of efficacy during treatment with diazepam, phenobarbital, levetiracetam and unspecified benzodiazepines for status epilepticus [not all routes and dosages stated]. The woman, who had a history of obesity and a seizure disorder, presented to the emergency department (ED) with status epilepticus, which was refractory to diazepam. She had been receiving phenytoin for status epilepticus. On arrival, she had blood in the oropharynx from bite lacerations to her tongue. At ED, she received phenobarbital 1g, levetiracetam 1g and multiple doses of unspecified benzodiazepines without any effect. Therefore, she was started on vecuronium bromide [Vecuronium], and a complete relaxation was noted to facilitate the intubation. Due to ongoing tongue bleeding, numerous attempts to perform direct laryngoscopy and videolaryngoscopy were unsuccessful. As a result, a King LT supraglottic device (SGD) was placed with initial adequate oxygenation and ventilation. It was decided to transfer her to a tertiary care centre. She was found to have palpable crepitus throughout her neck and chest, which had progressed to massive subcutaneous emphysema, moving across both breasts and abdomen. Considering her rapidly worsening crepitus and necessity of secured airway, a bilateral chest decompressions using was performed with a bilateral audible rush. Subcutaneous air evacuation was tried with direct pressure to the chest. Then endotracheal intubation was attempted three times with videolaryngoscopy; however, it was unsuccessful. Tracheostomy was attempted but later it was aborted due to unrecognizable landmarks. At the same time, she had a pulseless electrical activity arrest and a cardiopulmonary resuscitation was performed. Following 6 minutes, a spontaneous blood circulation was achieved. Thereafter, efforts were made to expel subcutaneous air via the superficial skin incisions. Also, an additional attempt for intubation was performed, which was successful. Thereafter, she was transferred to the tertiary care centre. It was found that, she had subtherapeutic levels of phenytoin, which was a possible cause of status epilepticus. Further examination revealed persistent massive subcutaneous emphysema in spite of prior expulsion of air; however, minimal pneumothoraces were noted. It was noted that the possible cause of subcutaneous emphysema was an oropharyngeal or tracheal injury, which was occurred during intubation attempts or SGD placement. Eventually, she underwent a tracheostomy for airway protection, which resulted in full recovery of her neurologic status. Muszalski C, et al. Massive Subcutaneous Emphysema Leading to Airway Distortion. Journal of Emergency Medicine 57: 877-879, No. 6, Dec 2019. Available from: URL: 803501558 http://doi.org/10.1016/j.jemermed.2019.09.015

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