Obstructive Segmental Emphysema After Chest Trauma

Abstract

A three month old white girl was involved in an accident in which she was lying on the rear seat of an automobile when it struck a telephone pole causing the infant to be thrown forcibly into the back-rest of the front seat. She was admitted to St. Luke’s Hospital immediately on August 24, 1956 when she appeared to be in acute respiratory distress. There was stnidor, indnawing of the intercostal spaces, especially noted on the right. Respiratory rate was markedly increased (40/mm.) , pulse rapid (130) , and there was cincumoral pallor. She was placed in an oxygen tent and x-ray films of the chest were taken. The following day when seen by one of the authors, in addition to the stated findings, there was notable cyanosis. The presence of shifted mediastinum and the absence of peripheral lung markings with atelectasis of the lower lobe suggested the diagnosis of tension pneumothorax of the right chest. A chest catheter was introduced into the pleural space and attached to under-water seal drainage. There was immediate improvement in her condition. During the next two weeks her pulmonary status seemed to stabilize and she was discharged to the cane of her pediatrician. A careful history and examination of the natal records showed no evidence of previous pulmonary disease. Her physician considered the child completely normal prior to the described injury. On January 23, 1957 she was neadmitted to the hospital with the signs of acute lower respiratory infection. She seemed extremely ill. The syndrome of stnidor, indrawing of the right intercostal spaces and cyanosis was again apparent. Her rectal temperature was 104#{176} and pulse 140. Examination of the chest showed hyper-resonance on the right side with absent breath sounds. The right side of the chest appeared to be fixed in the inspiratory position. X-ray film showed increased air content on the right, peripheral lung markings were absent, and marked mediastinal shift to the left with an apparent henniation of right lung through the anterior mediastinum. A tentative diagnosis of traumatic lung cyst was entertained. She was treated supportively and with antibiotics. Again there was a regression of symptoms and with pulmonary stabilization but with persisting insufficiency. A decision was made to explore but because of repeated severe episodes of lower respiratory infections, surgery was postponed. On October 22, 1957 right thoracotomy was performed.