1

What is the most common mechanism of chest or abdominal trauma in children?

Blunt trauma in pediatric patients accounts for approximately 90% of injuries, usually sustained from falls, motor vehicle collisions (MVC) or other vehicle-related accidents (e.g., auto vs. pedestrian or bicycle), and nonaccidental trauma.

Penetrating trauma less commonly occurs from gunshot wounds (GSW), stabbing, or impalement.

2

How do injury patterns differ in children compared to adults who sustain thoracic trauma?

The chest wall of a child is more compliant than an adult’s, so serious intrathoracic injuries may occur without rib fractures or even obvious physical signs on the chest wall. Due to their compliant musculoskeletal structures, rib fractures require more significant force than compared to the same fractures in adults and are therefore a red flag for severe injury.

1

What is the most common mechanism of chest or abdominal trauma in children?

Blunt trauma in pediatric patients accounts for approximately 90% of injuries, usually sustained from falls, motor vehicle collisions (MVC) or other vehicle-related accidents (e.g., auto vs. pedestrian or bicycle), and nonaccidental trauma.

Penetrating trauma less commonly occurs from gunshot wounds (GSW), stabbing, or impalement.

4

A 3-year-old girl is brought to your urgent care after a 5-foot fall at the playground. What are assessment and management priorities in examination of a pediatric patient with traumatic injuries to the chest and abdomen?

The initial management should be to identify and stabilize any life-threatening injuries. Airway, breathing, and circulation are essential and part of any traumatic primary exam. If any component of the trauma primary exam is absent or severely compromised, emergent intervention is needed; immediately transfer to a higher level of care. Any hemodynamically unstable child with suspected intrathoracic or intraabdominal injury needs to be stabilized emergently and should be transferred to an emergency department with trauma capabilities for resuscitation and possible operative intervention.

5

What additional information should be gathered after a traumatic event?

Gather information regarding mechanism from witnesses if available. Obtain a history from the patient or the patient’s family, and perform a thorough secondary physical exam. Key elements of the patient include mechanism of injury, time since the injury, and the patient’s presentation at the scene of the injury. Was there any loss of consciousness? Were there any witnesses to the injury?

Does the patient complain of any chest pain or abdominal pain? Any difficulty breathing? Nausea or vomiting? Has the patient been able to tolerate food?

6

What are major considerations in motor vehicle accidents?

Was the patient restrained? Was the patient in a car seat; facing forward or backward? Where in the car was the patient seated? Where was the impact on the vehicle? Were any other people in the accident severely injured? How fast was the vehicle traveling and were airbags deployed?

7

What is important history to obtain in penetrating trauma?

If the penetrating trauma was due to gunshot, how many shots were fired? If the wounds were due to impalement, how long was the object that penetrated the patient? Was the whole object removed and witnessed to be intact?

8

When should you consider nonaccidental trauma?

Any serious injury such as intracranial hemorrhage, a long bone fracture (except a spiral tibial fracture), or hollow viscous injury should have a significant mechanism of injury on history. Any discrepancy between the history and the physical or diagnostic findings or sign of significant force (such as a rib fracture) should prompt you to consider inflicted injury. Consider if a mechanism of injury is inconsistent with a patient’s developmental abilities (e.g., bruising in a young infant). Any pattern injury is concerning for inflicted injury (bruising/burns/marks that correspond to infliction with instruments or do not occur through natural play environmental interactions). Also, note frequent visits for injuries. Children with inflicted injuries may present with multiple visits for injuries that may not individually raise concern.

9

A 1-year-old boy comes to your urgent care after a fall from a bed. Your primary exam is normal. Describe key components of the secondary exam of the chest in a pediatric trauma patient.

Evaluate respiratory status including breath sounds, respiratory rate, and signs of distress such as nasal flaring or retractions. Assess the chest wall for focal tenderness, crepitus, abrasions, ecchymosis, or lacerations. Remember that open wounds may be the track of a penetrating wound. Paradoxical chest wall movement is important to note because a flail segment bulges during expiration. Decreased or absent breath sounds may indicate pneumothorax, hemothorax, or pulmonary contusion. Distant or muffled heart tones may suggest hemopericardium. Injury to the great vessels may result in hypotension, peripheral pulse abnormality, or neurologic deficit.

10

What are the red flag physical exam findings after chest and abdominal trauma?

Respiratory distress in a child after trauma is a red flag for serious injury and potential for decompensation. Chest pain with neck discomfort is concerning for mediastinal free air; and distended neck veins are associated with pericardial tamponade. Children should be transferred to the emergency department for further evaluation with any abnormalities of lung auscultation, respiratory rate, chest rise pattern, and oxygen saturation.

In abdominal trauma, focal tenderness, distension, vomiting, and bruising are red flags for injury. Any sign of rigidity or rebound tenderness is a late finding and concerning for severe abdominal injury.

11

A 7-year-old girl comes to your urgent care after she was a passenger in a motor vehicle accident. On physical exam you find what is shown in Fig. 27.1 . What is the name of this physical finding and what is its significance?

This is a seat belt sign. It is ecchymosis due to the acceleration and deceleration of the body against a seat belt in an MVC.

Seat belt sign in a pediatric patient.

Children with seat belt signs from MVCs are almost three times more likely to suffer an intraabdominal injury (IAI) and are over ten times more likely to suffer gastrointestinal injuries such as hollow viscous or mesentery.

A child with a seat belt sign should be transferred to the emergency department as there is a significant associated risk of IAI. Further investigation is required including serial abdominal exams, laboratory studies, and frequently CT scan.