An 8-year-old girl presented to the emergency department 72 hours after sustaining blunt trauma to the chest during a bumper car rear-end collision when she was thrown forward into her seatbelt. She complained of chest pain and worsening shortness of breath. She had a history of asthma for which she had never been admitted to the hospital and was not taking any medications. Her vital signs and oxygen saturation were stable upon admission. Pulmonary auscultation revealed diminished breath sounds in the lower half of the right lung. The patient's chest radiography showed atelectasis of the lower half of the right lung (Fig. 1). A CT scan revealed complete obstructive atelectasis of the right middle and lower lobes and ground-glass opacity in the right upper lobe (Fig. 2). There was no abdominal lesion. The history of trauma, clinical presentation and radiological findings led to a diagnosis of a pulmonary contusion following blunt trauma and complicated by obstructive atelectasis. Few hours after admission, patient's respiratory state deteriorated with polypneic breathing, chest retractions and hypoxemia (pulsed oximetry 80%). She was transferred to the pediatric intensive care unit where nasal high-flow oxygen therapy (oxygen flow rate of 15 L/min, fraction of inspired oxygen up to 0.3) was administered for 48 hours. Although stabilized, dyspnea persisted and required nasal oxygen (3-4 L/min) for a week. Chest physiotherapy did not result in marked expectoration. Chest radiography and CT scan on day 7 showed no improvement. A bronchoscopy was performed on day 8 and revealed a large mucous plug occluding the right main bronchus. There were no underlying endobronchial lesions, nor foreign bodies. The right lung fully expanded after the plug was removed. The patient's breathing also improved substantially. Haemophilus influenzae was found in sputum culture at a concentration of 105 colony-forming units per mL and treated with amoxicillin/clavulanic acid. As the patient presented recurring coughing during exercise, inhaled corticosteroids were also prescribed, alongside with inhaled short-acting beta 2-agonists as needed.
Admission CT-scan showing complete obstructive atelectasis of the right middle and lower lobes and ground-glass opacity in the right upper lobe consistent with a pulmonary contusion in an 8-years old girl after bumper car collision.