Case 44: Surgical Emphysema After a Motor Vehicle Accident

Abstract

A 16-year-old boy (65 kg) is admitted to the hospital after a motor vehicle accident in which he was a passenger in the front seat. The boy was thrown toward the dashboard because he was not wearing a seatbelt. His only medical complaint is that he is partially deaf and wore a hearing aid that was lost on arrival to the hospital. He can therefore neither hear nor understand what is being said to him. His mother is there to comfort him. His ability to use sign language is poor. The patient has no history of drug allergy. On examination, the boy is found to be otherwise healthy with stable vital signs, except for a fractured right clavicle and surgical emphysema over his anterior neck and right supraclavicular fossa. There are many abrasions. Hematocrit (Hct) is 38 %, and the electrocardiogram (ECG) is normal. The chest X-ray shows a fractured right clavicle and mediastinal emphysema. The right lower lobe is collapsed. A computed tomography (CT) scan of his cervical spine and abdomen is normal. The thoracic CT scan reveals, again, air in the anterior chest wall and superior and anterior mediastinum. The thoracic surgeon diagnoses a bronchial tear that now has hopefully sealed and elects to observe him in the intensive care unit (ICU). Initially he does well, but on the third day after admission he becomes febrile and develops a productive cough. You take him to the operating room and induce general anesthesia. Through an endotracheal tube (ETT), the thoracic surgeon performs a fiber-optic bronchoscopy and sees no bronchial tear. The surgeon aspirates thick secretions and old blood from the right lower lobe. After this procedure, the patient improves sufficiently to be discharged 5 days later. Four days after his discharge, he arrives back in your emergency room with inspiratory stridor. He is transferred to the ICU where you meet him again. Arterial blood gas on room air is pH 7.38, PO₂ is 52 mm Hg, PCO₂ is 46 mm Hg, and base excess is −3 mmol/l. A chest X-ray reveals a small left pneumothorax and persistent mediastinal emphysema. He still does not have a hearing aid.