BACKGROUND
Extensive subcutaneous emphysema (SE) can complicate blunt chest trauma and interfere with bedside ultrasonography by preventing adequate visualization of deeper structures. We report a case of rapidly progressive Grade 5 SE in which extensive subcutaneous air rendered the initial extended Focused Assessment with Sonography for Trauma (E-FAST) technically non-diagnostic.
CASE REPORT
A 45-year-old man presented after a 1.5-meter fall onto his chest. He was initially hemodynamically stable with diminished left-sided breath sounds and localized subcutaneous crepitus. Within approximately 10 minutes of emergency department (ED) admission, SE progressed to involve the face, neck, trunk, all 4 extremities, and scrotum, accompanied by worsening dyspnea and tachypnea. E-FAST was technically limited and non-diagnostic because of extensive subcutaneous air artifacts. Computed tomography (CT) demonstrated multiple rib fractures, pulmonary lacerations, pneumothorax, hemothorax, pneumomediastinum, and hepatic laceration. Following CT imaging, bilateral infraclavicular blowhole incisions were performed for subcutaneous decompression, while the traumatic pneumothorax and hemothorax were managed concurrently with tube thoracostomy. Respiratory symptoms improved within minutes. The patient remained hemodynamically stable, did not require mechanical ventilation or operative management, and was discharged after clinical and radiological improvement.
CONCLUSIONS
Extensive SE can render E-FAST technically limited and non-diagnostic and should not be interpreted as a true negative examination. In rapidly progressive symptomatic SE, management should be guided by the evolving clinical condition, with subcutaneous decompression considered alongside definitive treatment of the underlying thoracic injury.

Keywords: Subcutaneous Emphysema; Traumatology; Ultrasonography