Philly, a seven year old female spayed Domestic Longhair feline, presented as an emergency to Hickory Veterinary Hospital on March 3, with an episode of acute tachypnea.
Upon initial examination, the patient had a normal temperature, an elevated heart rate, and a mildly elevated respiratory rate with a moderately elevated respiratory effort. The mucous membranes were slightly tacky but pink and the capillary refill time was about one and one half seconds, therefore oxygenation of the pet was deemed sufficient and no flow-by oxygen was required. While handling the patient, the technician noticed severe subcutaneous emphysema along the right side of the patient's ventral thorax, extending along the abdomen as well as by the right side of the neck.
During the patient's assessment, the physician confirmed the sinus tachycardia as well as a grade I/VI left parasternal systolic heart murmur. The heart also seemed somewhat shifted to the left side of the patient's chest. Increased bronchovesicular lung sounds were perceived on the left side of the ventral thorax as well as dull to absent lung sounds on the right ventral thorax and crackles with subcutaneous emphysema on the right dorsal thorax. Both pupils were of equal size and reactivity and a fundic exam was within normal limits. No oculonasal discharge was present, and an oral exam was unremarkable except for a few possible tiny bite marks along the tip of the tongue. Abdominal palpation revealed a left kidney slightly larger than the right, normal gastrointestinal loops, and a small normal bladder, with all internal organs seemingly intact. After thorough examination of the patient's entire skin coat, no obvious puncture could be found besides a slight scrape over the right ventral neck near the trachea that was not obviously communicating.
Radiographs were taken to confirm a possible diagnosis of suspect respiratory trauma in either the trachea or the lungs; to include thoracic body wall trauma. These films demonstrated substantial subcutaneous emphysema, a diffuse increased alveolar opacity, and a gas pocket between the eighth and ninth ribs, all visualized on the right lateral thorax. No obvious masses or broken ribs were appreciated, though the heart was lifted off of the sternum by surrounding air, indicating collapse of a lung lobe and pneumothorax. After prepping the right side of the patient for sterility, 125 milliliters of air were removed from the right subcutaneous space. Almost immediately after the procedure, air began to re-accumulate in the area and the skin was moving up and down with each breath of the patient dorso lateral near the eighth and ninth ribs. The physician consulted with the attending surgeon about the likelihood of body wall trauma and communication between the pleural space and the subcutaneous region. Surgery was performed in order to explore and repair the suspected area of trauma.
The attending surgeon placed Philly under general anesthesia and a lateral incision was made to explore the chest wound. A tear was noted through muscle with a rent between her ribs through her thoracic wall. A culture was taken from the wound location. A chest tube was placed. The wound was closed primarily with PDS and nylon suture. Air was evacuated through the chest tube until there was negative pressure present. A post operative radiograph was taken to insure chest tube placement and a bandage was placed around her chest to help secure the chest tube. The surgeon notified the owners of Philly’s post operative recovery. She informed the client that we would continue to monitor the air coming from the chest tube. If air should reform during Philly’s monitoring then we would be concerned that there was lung trauma. Philly would then require a more extensive exploratory of her thoracic cavity. Philly was placed on intravenous antibiotic, pain management and maintenance intravenous fluid therapy. Philly’s respiration effort, respiratory rate, temperature and evacuation of chest tube were monitored closely for the next forty eight hours.
Philly was improving and showed less discomfort within four to six hours post operatively. Radiographs were taken twice a day to monitoring Philly’s chest. Twenty four hours after surgery Philly was eating and eliminating well. The chest tube was removed and the bandage replaced. There was minimal subcutaneous emphysema present. She was placed on Baytril (Enrofloxacin) 22.7mg once a day, Clavamox (Amoxicillin + Clavulanate Potassium) 62.5mg twice a day and Buprenex (Buprenorphine Hydrochloride) as needed for pain relief. Just a little over 1 and ½ days post operatively she continued to eat and eliminate without distress. Philly’s CBC was repeated and results were all within normal limits. Her culture and sensitivity results were negative. Philly’s was discharged that evening. The owner was asked to monitor Philly’s temperature at home and call us if she should become inappetent, lethargic or she developed a fever.
Philly was examined fifteen days post surgery and had her sutures removed. The emphysema had resolved and the incision was healed. Bloods never mentioned earlier elevated liver enzymes. A little over seven weeks from the initial trauma Philly’s recheck and blood work were all within normal limits. Philly had recovered from her flail chest and was back to normal.
Written By Katie Umstetter
Internal Medicine Technician