Overview
Classification
- Blunt trauma: an injury caused by the application of a mechanical force by a blunt force or object
- Penetrating trauma: an injury caused by a cutting or piercing instrument that interrupts the continuity of tissues
Epidemiology
- Infrequent: 10% of pediatric trauma
- Rarely occurs in isolation, up to 85% of cases are associated with polytrauma
- Majority due to motor vehicle accidents and falls
- 7%–8% of cases are due to abuse and usually occur in individuals < 3 years of age.
- Blunt trauma:
- 85% of cases due to blunt trauma
- > 50% of cases of blunt thoracic trauma are associated with head, abdomen, and limb injuries.
- Penetrating trauma: more often due to gunshot wounds
- Overall mortality: 15%–26%
Pathophysiology and anatomy
The thoracic region of a child is more compliant compared to that of adults:
- Flexible ribs:
- Due to a lesser degree of ossification
- Transmission of trauma energy to the lung parenchyma → lung contusions
- Unlikely to fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures: Fractures indicate high-energy mechanisms and internal injury.
- The
mediastinum
Mediastinum
The mediastinum is the thoracic area between the 2 pleural cavities. The mediastinum contains vital structures of the circulatory, respiratory, digestive, and nervous systems including the heart and esophagus, and major thoracic vessels.
Mediastinum and Great Vessels is more mobile:
- More drastic visceral displacement
- Loss of preload and hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
- Lower pulmonary reserve
Common Thoracic Injuries
| Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax |
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| Hemothorax |
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| Lung parenchymal injury or lung contusion |
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| Rib fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures |
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| Blunt cardiac injury or cardiac contusion |
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| Injuries to the aorta and great vessels |
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| Esophageal injury |
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| Diaphragmatic injury |
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| Traumatic asphyxia |
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| Tracheobronchial injury |
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| Penetrating trauma | Gunshot wounds are an increasingly common cause. |
Assessment
Primary survey
- Airway:
- Check for airway patency.
- Obstruction often due to blood or secretions
- Breathing:
- Look at, listen to, and feel the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall for breathing.
- In cases of pneumothorax, hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax, or flail chest Flail chest Flail chest is a life-threatening traumatic injury that occurs when 3 or more contiguous ribs are fractured in 2 or more different locations. Patients present with chest pain, tachypnea, hypoxia, and paradoxical chest wall movement. Flail Chest, breathing may be asymmetric.
- Circulation:
- Palpate peripheral and central pulses.
- Obstructive shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock in cardiac tamponade Cardiac tamponade Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade and tension pneumothorax
- Disability:
- Assess the level of alertness.
- GCS < 8 is an indication for emergent intubation.
- Exposure:
- Complete; head-to-toe examination for other injuries
- As a shortcut, when the affected individual speaks, it is an indication of:
- A patent airway
- Proper breathing
- Sufficient circulation and perfusion of the brain
- Helpful in assessing mental status
| A | B | C |
|---|---|---|
| Airway obstruction Airway obstruction Airway obstruction is a partial or complete blockage of the airways that impedes airflow. An airway obstruction can be classified as upper, central, or lower depending on location. Lower airway obstruction (LAO) is usually a manifestation of chronic disease, such as asthma or chronic obstructive pulmonary disease (COPD). Airway Obstruction or tracheobronchial rupture |
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Secondary survey or evaluation
- Abbreviated history:
- Mechanism of injury (e.g., acceleration or deceleration)
- Careful head-to-toe inspection; in chest trauma look specifically for:
- Abnormal respiratory rate
- Tracheal deviation
- Beck’s triad: low blood pressure, muffled heart sounds Heart sounds Heart sounds are brief, transient sounds produced by valve opening and closure and by movement of blood in the heart. They are divided into systolic and diastolic sounds. In most cases, only the first (S1) and second (S2) heart sounds are heard. These are high-frequency sounds and arise from aortic and pulmonary valve closure (S1), as well as mitral and tricuspid valve closure (S2). Heart Sounds, raised jugular venous pressure
- Paradoxical chest movements (e.g., flail chest Flail chest Flail chest is a life-threatening traumatic injury that occurs when 3 or more contiguous ribs are fractured in 2 or more different locations. Patients present with chest pain, tachypnea, hypoxia, and paradoxical chest wall movement. Flail Chest)
- Crepitus with subcutaneous emphysema
X-ray showing multiple rib fractures in an infant
Image: “Fractures of ribs in an infant” by National Institute of Health. License: Public Domain
Pulmonary contusion on a chest X-ray:
Image: “Diffuse bilateral lung infiltrates” by Centre de Santé et de Services Sociaux de Trois-Rivières, 1991 Boul, du Carmel, Trois-Rivières, QC G8Z 3R9, Canada. License: CC BY 2.0
See the diffuse “spotting” of the right hemithorax.
Hemothorax on a chest X-ray:
Image: “Chest X-ray shows massive right hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax” by Cardiac Surgeon, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK. License: CC BY 2.0
See the “white-out” phenomenon produced by the blood trapped in the pleural space.
A widened mediastinum Mediastinum The mediastinum is the thoracic area between the 2 pleural cavities. The mediastinum contains vital structures of the circulatory, respiratory, digestive, and nervous systems including the heart and esophagus, and major thoracic vessels. Mediastinum and Great Vessels in a chest X-ray seen in cases of aortic disruption
Image: “Frontal chest radiograph shows mediastinal widening” by Department of Radiodiagnosis, R.N.T. Medical College and Associated Group of Hospitals, Udaipur (Rajasthan)-313 004, India. License: CC BY 2.0
Workup
- Diagnostic imaging:
- Ultrasound (eFAST) in cases of hemodynamic instability
- Chest X-ray: to determine rib fractures, areas of consolidation (lung contusion), pneumothorax, and hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax
- CT: to determine aortic disruption and hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax
- Bronchoscopy and laryngoscopy: to identify lack of continuity in the upper airways and bronchial tree Bronchial tree The collective term "bronchial tree" refers to the bronchi and all of their subsequent branches. The bronchi are the airways of the lower respiratory tract. At the level of the 3rd or 4th thoracic vertebra, the trachea bifurcates into the left and right main bronchi. Both of these bronchi continue to divide into secondary or lobar bronchi that bifurcate further and further. Bronchial Tree
- Esophagoscopy: to determine lack of continuity of the esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus
- Laboratory assessments: troponin levels to rule out blunt cardiac injury
- ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG): to check for arrhythmias
Management
Management depends on the injury (rapid initiation of high-quality CPR if the individual fails the airway, breathing, circulation (ABC) assessment).
Supportive management
- Monitoring of vital signs
- Maintain airway: Intubate if necessary.
- Maintain oxygenation:
- Supplemental O2
- Positive pressure ventilation, if necessary
- Maintain blood pressure/perfusion:
- Isotonic crystalloids or blood transfusion, if necessary
- Vasopressors
Life-threatening injuries
- Tension pneumothorax: needle decompression and chest tube
- Open pneumothorax: 1-way valve
- Flail chest:
- Supportive care: intubation and mechanical ventilation
- Surgical fixation of chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall when necessary
- Hemothorax: tube thoracostomy or thoracotomy in cases of severe bleeding
- Injuries to the aorta and great vessels: surgical intervention
- Penetrating injuries:
- Fluid resuscitation
- Surgical intervention in individuals with chest tube output > 2 mL/kg/h
References
- Kuo, D.Z., Houtrow, A.J. (2016). Recognition and management of medical complexity. Pediatrics, 138, 1. https://search.proquest.com/docview/1846002393
- Gutiérrez, C.E. (2016). Pediatric trauma. In J. E. Tintinalli, J.S. Stapczynski, O.J. Ma, D.M. Yealy, G.D. Meckler, D.M. Cline (Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill Education. accessmedicine.mhmedical.com/content.aspx?aid=1121492666
- Roskind, C.G., Pryor, H.I., Klein, B.L. (2020). Acute care of multiple trauma. In R.M. Kliegman MD, J.W. St Geme, N.J. Blum, S.S. Shah, MSCE, R.C. Tasker, K.M. Wilson (Eds.), Nelson Textbook of Pediatrics (pp. 54-554.e1). https://www.clinicalkey.es/#!/content/3-s2.0-B9780323529501000821
- Dubois, S.M. (2011). Trauma de tórax. In S. Martínez Dubois (Ed.), Cirugía bases del conocimiento quirúrgico y apoyo en trauma, 5e. New York, NY: McGraw-Hill Education. accessmedicina.mhmedical.com/content.aspx?aid=1118391901
