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Case Report Thoracic Trauma and Post Operative Lung Injury in a Neonatal Foal A

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Case Report Thoracic Trauma and Post Operative Lung Injury in a Neonatal Foal A 186 EQUINE VETERINARY EDUCATION / AE / april 2009 Case Report Thoracic trauma and post operative lung injury in a neonatal foal A. Borchers, A. van Eps†, S. Zedler‡ and P. A. Wilkins* Department of Clinical Studies Sections of Emergency, Critical Care and Anesthesia; †Medicine; and ‡Surgery, University of Pennsylvania, School of Veterinary Medicine, New Bolton Center, Kennett Square, Pennsylvania, USA. Keywords: horse; rib fractures; parenchymal pulmonary disease Summary are characterised by noncardiogenic pulmonary oedema and pulmonary inflammation resulting in acute respiratory A 24-hour-old Standardbred filly was referred with an dysfunction (DeClue and Cohn 2007; Wilkins et al. 2007). acute history of weakness, respiratory distress and There are no prior reports in the literature detailing subcutaneous emphysema. Radiographic evaluation pulmonary injury in neonatal foals after thoracic trauma. revealed left sided rib fractures, unilateral pneumothorax This Case Report discusses pulmonary injury based on serial and pneumomediastinum. Serial arterial blood gas arterial blood gas (ABG) analyses, consecutive thoracic measurements pre- and post rib repair showed pulmonary radiographs and the medical management of a neonatal dysfunction. Post operative radiographs revealed the foal with rib fractures and evidence of impaired presence of air bronchograms and a bronchointerstitial pulmonary function before and after surgical repair. pattern, suggestive of alveolar parenchymal pathology consistent with pulmonary contusion, pulmonary oedema Case details or ALI/ARDS. The filly was treated with intranasal oxygen and an active chest draining unit and recovered History uneventfully. A one-day-old Standardbred filly, born to a multiparous Introduction mare at 338 days of gestation, presented with a history of weakness, respiratory distress and diffuse subcutaneous Severe thoracic injury with post traumatic parenchymal emphysema over the left neck and thorax. Stage 2 labour lung disease influences morbidity and mortality in human was prolonged and lasted 45 min. The filly was delivered trauma patients (Keel and Meier 2007). Thoracic injury in via assisted vaginal delivery that included manipulation veterinary medicine includes penetrating chest wounds and traction applied to the thoracic limbs. Following (Hance and Robertson 1992; Hassel 2007), rib fractures delivery the foal was apnoeic and required (Jean et al. 1999, 2007; Bellezzo et al. 2004; Kraus et al. cardiopulmonary resuscitation (CPR). Resuscitation was 2005) and flail chest (Olsen et al. 2002) resulting in successful but the filly was slow to stand and to nurse. complications including subcutaneous emphysema, Serum IgG concentration (IgG) 12 h after parturition was pneumothorax, pneumomediastinum, haemothorax, greater than 8 g/l. Over the next 24 h the filly became diaphragmatic hernia, pulmonary collapse and contusion, obtunded, weak and tachypnoeic. Diffuse subcutaneous myocardial lacerations and punctures and emphysema over the left neck and thorax became haemopericardium (Hance and Robertson 1992; apparent. The foal received 1 litre of Normosol-R1, i.v., Schambourg et al. 2003; Hassel 2007; Keel and Meier procaine-penicillin (1017 iu/kg bwt, i.m. once) and 2007). Acute lung injury (ALI) and acute respiratory distress gentamicin (0.6 mg/kg bwt, i.v., once) from the farm syndrome (ARDS) are secondary inflammatory responses manager prior to referral. to multiple lung injury including thoracic trauma. ALI/ARDS Clinical findings *Author to whom correspondence should be addressed. Present address: Department of Veterinary Clinical Science, 1008 West On presentation the filly was recumbent and depressed, Hazelwood Drive, Urbana, Illinois 61802, USA. with a body condition score of 4/9 and a bodyweight of EQUINE VETERINARY EDUCATION / AE / april 2009 187 TABLE 1: Arterial blood gas results during hospitalisation Hours after initial presentation Preoperatively Post operatively Hours 0 1.5 2 4 7.5 12 22 34 41 60 75 84 109 INO2 (l/min) RA 10 10 10 10 10 8 6 RA RA 3 RA RA pH 7.35 7.29 7.35 7.36 7.32 7.31 7.40 7.33 7.39 7.48 7.49 7.46 7.48 PaO2 (mmHg) 44.9 142 124 50.6 94.5 57.6 168 133 55.9 61.5 116 63.5 72.3 PaCO2 (mmHg) 63.4 75.9 65.6 61.7 69.9 72.6 51.7 69.2 57.6 48.4 45.9 48.9 43 O2Sat (%) 74.8 99.1 98.8 81.6 96.4 84.8 99 98.9 86.8 92 99.1 92.3 95.1 PaO2/FiO2 213 266 292 302 344 PAO2 (mmHg) 65 75.4 86.3 86.7 94.3 PAO2 - PaO2 20.1 19.5 24.8 23.2 22 INO2 = intranasal oxygen; PaO2 = partial pressure of oxygen in arterial blood; PaCO2 = partial pressure of carbon dioxide in arterial blood; O2Sat = oxygen saturation; FiO2 = fractional inspired oxygen concentration; PAO2 = partial pressure of oxygen in the alveolar gas; RA = room air. 59 kg. Moderate flexor tendon laxity was present in all subcutaneous emphysema. Bronchovesicular lung sounds limbs. The mucous membranes were pink and moist with a were auscultated over the right hemithorax. The capillary refill time of 2 s. Peripheral pulse quality was strong remainder of the physical examination was unremarkable. and the distal extremities and ears were warm to the The foal was moderately haemoconcentrated at touch. Other physical examination findings included admission (packed cell volume 46%, reference range [rr] severe diffuse subcutaneous emphysema over the left 30–42%) and plasma fibrinogen concentration was mildly neck, thorax and abdomen with painful responses increased at 3.3 g/l (rr 1–3 g/l). Plasma IgG concentration localised to the left mid thoracic area. Thoracic was 8.3 g/l. Other plasma clinical chemistry abnormalities auscultation revealed tachycardia (100 beats/min), included increased creatinine-kinase activity at 12,339 u/l a restricted, shallow, periodic breathing pattern at (rr 90–270 u/l) and increased total bilirubin concentration 24 breaths/min and a rectal temperature of 38.9°C. A at 117 µmol/l (rr 1.7–32.5 µmol/l). A blood culture obtained grade 1/6 systolic murmur and a ‘mechanical clicking’ on admission was negative for bacterial growth. Arterial were auscultated over the right heart base. Auscultation blood gas (ABG) analysis obtained in lateral recumbency of left heart and thorax was not possible due to on room air revealed hypercapnia, hypoxaemia and an oxygen saturation of 74.8% (Table 1). Thoracic radiographs in right lateral recumbency revealed a diffuse interstitial to alveolar pattern, subcutaneous emphysema, unilateral (left) pneumothorax, Fig 1: Thoracic radiograph of a neonatal foal with diffuse subcutaneous emphysema, pneumomediastinum and pneumothorax in right lateral recumbency. There is air contrast around the oesophagus and trachea and caudal displacement Fig 2: Caudo-dorsal radiographs of the same foal in right lateral of the cardiac silhouette indicating pneumomediastinum recumbency. Note the outline of the collapsed dorsal margin of (black arrows). the left lung lobe (white arrows) indicating pneumothorax. 188 EQUINE VETERINARY EDUCATION / AE / april 2009 pneumomediastinum and fractures of ribs 8–9 of the left hemithorax (Figs 1 and 2). Ultrasonographic imaging of the fractured ribs of the left hemithorax was attempted but unsuccessful due to the extent of the subcutaneous emphysema; ultrasonographic examination of the right hemithorax showed normal lung tissue, normal cardiac structures and no evidence of rib fracture. A problem list after the initial evaluation included recumbency, rib fractures of the left hemithorax, pneumothorax, pneumomediastinum, diffuse subcutaneous emphysema over the left neck, thorax and abdomen, diffuse interstitial to alveolar pattern on thoracic radiographs, hypoxaemia and hypercapnia. Case management To relieve the pneumothorax a teat cannula was placed caudodorsally using sterile technique between the 10th and 11th ribs and 250 ml of air was manually evacuated with a syringe. An ABG obtained immediately prior to aspiration demonstrated respiratory acidosis with moderate hypercapnia (Table 1, 1.5 h). An ABG obtained Fig 3: Thoracic radiographs taken immediately post operatively in after aspiration of air from the thorax showed an improved right lateral recumbency show moderate to severe diffuse bronchointerstitial and alveolar pattern. PaCO2 with resolution of the respiratory acidosis (Table 1, 2 h). Further treatment included placement of a 16 gauge maintained with sevoflurane10 in oxygen. During left jugular vein catheter2 under sterile conditions and anaesthesia the filly was hypoventilating and was therefore administration of 5% dextrose in water1 i.v., at 4 mg maintained on positive pressure mechanical ventilation dextrose/kg bwt/min, intranasal O2 at 10 l/min (170 ml/kg with a positive end expiratory pressure of 4 cmH2O. bwt/min, intranasal cannula); 1 unit (900 ml) of Fractures of the 5th–11th ribs were identified at surgery. hyperimmune plasma3 for supplementation of There was severe disruption of the associated pleura and immunoglobulin, coagulation factors and anti-endotoxin displacement of the ventral fragments of the 6th–9th ribs effects; magnesium sulphate4 (10% solution at 42 mg/kg into the thorax. The 6th–11th rib fractures were repaired with bwt/h loading dose followed by 25 mg/kg bwt/h constant nylon monofilament suture as previously described (Kraus rate infusion) as a neuroprotectant; sucralfate5 (20 mg/kg et al. 2005). Recovery from anaesthesia was uneventful. bwt per os, q. 8 h) for gastric protection; and flunixin After surgery, the filly was treated with i.v. potassium- meglumine6 (0.5 mg/kg bwt i.v., q. 12 h) for analgesia and penicillin every 6 h, i.v. amikacin once daily and sucralfate, anti-inflammatory effects. Antimicrobial treatment per os, 3 times daily. Butorphanol (0.015 mg/kg bwt i.m., included amikacin7 (30 mg/kg bwt i.v., q. 24 h) and q. 8 h) was administered for analgesia for 48 h post potassium penicillin8 (3 x 104 iu/kg bwt i.v., q. 6 h). operatively. Intravenous Normosol-R and 10% dextrose in An ABG obtained 2 h following aspiration of air from water were administered as a constant rate infusion until the left hemithorax revealed moderate hypoxaemia and the foal was able to ambulate and nurse consistently from an indwelling thoracic tube (Argyle chest tube)9 was the mare.
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