A 55 year old male presents to the ED in respiratory distress with hypoxia, tachycardia, and tracheal deviation. The patient is stabilized after intubation and chest tube insertion. What's the diagnosis? (scroll down for answer) 

 Answer: Subcutaneous emphysema

• The radiographic 'ginkgo leaf sign' 
• Highly suggestive of an underlying pneumothorax (or a tracheo-bronchial injury).
• Exam will reveal chest wall  crepitance.
• The diffuse nature of the emphysema suggests need for bronchoscopy to evaluate for tracheo-bronchial injury.