Thoracic Trauma in Children
Patricio Herrera MD
Jacob C. Langer MD, FRCSC
EPIDEMIOLOGY
Thoracic trauma accounts for between 4.5% and 8% of the patients seen in a pediatric trauma center (Tables 10-1 and 10-2).1,2
Next to head injury, it is the second most common cause of mortality in pediatric trauma (Table 10-3).3
In multi-injured children, thoracic trauma increases mortality 20-fold.
When combined with head trauma, blunt chest injury has mortality of 40-70%.
Most common causes of thoracic trauma in children:
Motor vehicle accidents (MVAs).
Pedestrians.
Unrestrained passengers.
Bicycle riders.
Falls.
Thoracic trauma epidemiology varies according to social, economic, cultural, and geographic characteristics.
Frequency of highway car accidents, car-pedestrian accidents, extreme outdoors activities, socioeconomic status, and degree of unsupervised activities all determine incidence of thoracic trauma.
Trauma pattern among infants and teens differs:
Teens: more penetrating injury and more front seat injuries.
Resembles adult pattern.4
Thoracic trauma injuries will often result in abnormal ABCs, requiring:
Intubation.
Chest tube insertion.
Fluid and possible blood administration.
10% will need emergency surgery to control bleeding or air leak from lung.
PATHOPHYSIOLOGY
Compliant chest wall results in more forces transmitted to internal organs, rather than rib fractures.
The increased tissue elasticity results in increased mediastinal mobility.
Therefore, tension pneumothorax requires lower pressures and develops more rapidly.5
More prone to hypoxia due to:
Higher metabolic rate.
Increased oxygen consumption per kilogram of body mass.
Reduced functional residual capacity.
Reduced cardiac capacity for compensation of hypovolemia because of two mechanisms:
Stiffness of ventricular wall.
Limited improvement by increasing heart rate from tachycardia.
Children at greater risk for rapid decompensation when exposed to trauma to the chest or trauma with hypovolemia.
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TABLE 10 – 3 Mortality Associated with Thoracic Injuries, Overall and Stratified by Diagnosis | ||||||||||||||||||||
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CLASSIFICATION
Chest injuries are divided according to mechanism of injury, (e.g., blunt versus penetrating).
Blunt Trauma
Round or plain surface impacts or holds the chest, transferring energy to the chest wall and internal organs.
Chest wall’s elastic deformation delivers energy directly to internal organs, while deceleration mechanisms tend to hurt the mediastinal structures instead.
Penetrating Trauma
Object or fragment intrudes the rib cage, directly damaging or disrupting internal organs.
Position and orientation of the wound tract determine which organs will be injured.
Most frequent causes are gunshot wounds, stabbing, and impalement.
Mortality of gunshot injuries is up to 17%.6
Impalement is infrequent. Mainly from falls or falling objects, usually around the house or going over fences.
Do not remove penetrating objects either on the scene or in the ED. Must be removed in the operating room in a controlled setting.
INITIAL STEPS IN EVALUATION AND MANAGEMENT OF THORACIC TRAUMA
Patient evaluation follows ATLS/PALS principles.
ABCs with assessment of airway, breathing, and cervical spine stabilization.
See Chapter 2 on Primary and Secondary Survey for details.
Primary survey of chest focused on detecting and treating major life-threatening injuries (mnemonic ATOMCF):
Airway obstruction.
Tension pneumothorax.
Open pneumothorax.
Massive hemothorax.
Cardiac tamponade.
Flail chest.
Two broad groups of patients:
Awake and crying.
Unconscious.
A small, crying patient should be approached in a comforting manner.
Assess airway.
Give oxygen by face mask.
Assess breath sounds for symmetry.
Decreased breath sounds and hyperresonance suggest pneumothorax.
In an unconscious or comatose patient (GCS < 8):
Secure airway.
Assist breathing.
Maintain cervical spine immobilization.
Assess air entry by auscultation, and order CXR to ensure proper endotracheal tube placement.
Assess perfusion by palpating pulses and obtaining blood pressure.
Whether awake or unconscious, suspicion of a tension pneumothorax should be managed with immediate needle decompression.5
Do not delay intervention for CXR.
Suspect hypovolemia and give a normal saline bolus of 20 mL/kg to any patient with multiple or high-energy trauma.
Re-evaluate need for repeat boluses until improvement in hemodynamic profile is seen and adequate, age-matched urine output is obtained.
Expose chest completely and palpate gently looking for wounds, deformities, seatbelt or tire markings, crepitations, or tenderness.
Paradoxical movement of any segment of the chest wall should be documented and investigated.
Gunshot wounds should have a surface marker placed prior to obtaining chest x-ray.
HISTORY
Important features are:
Where was the child?
Was he or she wearing a seatbelt or in a car seat?
How was the child positioned after the accident?
Was it a prolonged extrication?
What is the clinical status of other members in the vehicle?
How much damage was there to the vehicle/bicycle?
Cars hit on the side carry a higher incidence of head and thoracic trauma, compared to front/rear impacts.7
PHYSICAL EXAM
Ensure complete exposure during primary survey.
Look for wounds in the axilla, perineum, back, or other hidden areas.
Main cause of cardiac tamponade is a small stab wound to one of the ventricles.
Three entities present with the following features:
Unstable patient, both hypotensive and hypoxemic.
Unresponsive to supplementary oxygen, with respiratory difficulty.
A patent airway.
Tension pneumothorax:
Absent or diminished breath sounds on one side.
Hyper-resonant on chest percussion.
Distended neck veins (unless hypovolemic).
A gush of air and immediate improvement should be experienced after needle decompression.
Massive hemothorax:
Absent or diminished breath sounds on affected side.
Dullness on chest percussion.
Jugular veins are flat because of hypovolemia.
Cardiac tamponade:
Normal or unremarkable auscultation and percussion.
Muffled heart sounds.
Distended neck veins (extremely rare in pediatric trauma as usually related to penetrating injury).
Pulsus paradoxus.
IMAGING
Obtain AP chest film and if there is high-energy trauma, obtain C-spine and pelvis films to complete primary survey.
Radiologic evaluation with chest CT should only be done when the patient is hemodynamically stable (Table 10-4).Related posts:
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