Management of Subcutaneous Emphysema of the Upper Trunk After Fall Injury
Immediately obtain chest radiography to identify pneumothorax or pneumomediastinum, as subcutaneous emphysema after trauma indicates significant chest wall injury requiring urgent intervention. 1
Initial Assessment and Stabilization
Assess for airway compromise first, looking specifically for stridor, accessory muscle use, tracheal tug, or chest wall recession, as subcutaneous emphysema can progress to life-threatening airway obstruction even without cardiorespiratory compromise. 1, 2 Note that patients can present with delayed deterioration—one case report documented rapid progression 24 hours post-fall with massive crepitus causing airway obstruction within 30 minutes of emergency department arrival. 2
Provide high-flow humidified oxygen and position the patient upright to promote venous drainage of subcutaneous air. 1 Use waveform capnography when available to detect early airway obstruction. 1
Monitor continuously for warning signs of deterioration: dysphagia, dysphonia, palpebral closure from facial swelling, or worsening breathlessness. 1, 2, 3 These indicate progression requiring escalation of care.
Diagnostic Workup
Obtain immediate chest radiography to identify the underlying source—pneumothorax is present in the majority of traumatic subcutaneous emphysema cases. 1, 4 The presence of subcutaneous emphysema after fall injury indicates severe chest wall injury and should prompt thorough evaluation for tracheobronchial injury, rib fractures, or occult pneumothorax. 4, 2
Treatment of Underlying Pneumothorax
If pneumothorax is identified, insert a small-bore chest tube (10-14 French) as there is no evidence that larger tubes (20-24 French) provide superior efficacy. 1 Place the tube in the 5th intercostal space, mid-axillary line using proper aseptic technique. 1
Never clamp a bubbling chest tube—this is the most critical pitfall to avoid, as clamping converts a simple pneumothorax into tension pneumothorax and dramatically worsens subcutaneous emphysema by forcing air into tissue planes. 1, 4, 5 If a chest tube is already in place and subcutaneous emphysema develops or worsens, immediately check for tube clamping, kinking, or displacement. 1, 4
Ensure the patient is managed in a setting with specialist nursing expertise when suction is applied to the chest drain. 1 Avoid applying suction too early in primary pneumothorax to prevent re-expansion pulmonary edema. 6, 5
Management of Severe or Progressive Subcutaneous Emphysema
Most subcutaneous emphysema is self-limiting and resolves within days without specific intervention. 4, 3 However, if the patient develops extensive emphysema with cutaneous tension, dysphagia, dysphonia, palpebral closure, or respiratory compromise despite chest tube placement:
Consider percutaneous decompression with large-bore angiocatheters (14-gauge) placed in the anterior chest wall subfascial space—this provides rapid decompression with complete resolution typically within 24 hours. 7, 8 This technique is simpler, safer, and more effective than large "blow hole" incisions or large-bore drains. 8
Alternatively, insert a large-bore fenestrated subcutaneous drain (26 French) maintained on low suction (-5 cm H₂O) for 24 hours, which provides effective decompression in severe cases. 3
Surgical Referral for Persistent Air Leak
Obtain thoracic surgical consultation at 3-5 days if air leak persists or if the lung fails to re-expand. 6, 5 Earlier referral at 2-4 days is warranted for patients with underlying lung disease, large persistent air leaks, or failure of lung re-expansion. 6, 5
Video-assisted thoracoscopic surgery (VATS) is the preferred surgical approach for persistent air leak, offering shorter hospital stays (3.66 days shorter than open thoracotomy) and fewer complications (99/1000 vs 138/1000). 5 Open thoracotomy with pleurectomy remains the procedure with the lowest recurrence rate for difficult cases. 6, 5
Critical Pitfalls to Avoid
- Never clamp a bubbling chest tube under any circumstances. 1, 4, 5
- Do not apply fully occlusive dressings to open chest wounds without close monitoring, as this traps air and worsens subcutaneous emphysema. 4
- Recognize that delayed presentations are possible—patients may appear stable initially then rapidly deteriorate. 2
- Maintain the patient nil per os (NPO) when airway compromise is present, as laryngeal competence may be impaired despite full consciousness. 1