Thoracic Trauma in Children

Instances of traumatic force applied to the chest are seen in 10% of the cases of pediatric trauma, usually in the context of motor vehicle accidents and falls. Chest trauma rarely occurs in isolation and is often associated with polytrauma. The 2 major mechanisms involve blunt and penetrating forces. 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, 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, 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, and lung contusions are the most common injuries. Treatment of affected children is very similar to that of adults, but unique pediatric pathoanatomy dictates important differences in approach and management.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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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

Table: Common thoracic injuries in children
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
  • Common (33% of cases)
  • Tension pneumothorax: sudden compromise in right heart filling
Hemothorax
  • Less common
  • Described as a chest “white-out” in X-ray
  • Hemothorax can contain up to 40% of the effective volume → signs of hemorrhagic 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
Lung parenchymal injury or lung contusion
  • Lung contusions and lacerations are predominant injuries.
  • Often occur without external signs of injury
  • Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, hemorrhage, and inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of alveolar spaces → ventilation/perfusion mismatch
  • 2 mechanisms: compression or tearing, and severe displacement
  • Alveolar bleeding produces hepatization.
  • Consolidated area on chest X-ray (difficult to differentiate from pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia or atelectasis Atelectasis Atelectasis is the partial or complete collapse of a part of the lung. Atelectasis is almost always a secondary phenomenon from conditions causing bronchial obstruction, external compression, surfactant deficiency, or scarring. Atelectasis)
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
  • Signifies severe injury due to high-impact forces
  • May result in 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
  • Can indicate child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child's health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse when high-energy mechanisms are lacking
Blunt cardiac injury or cardiac contusion
  • Seen in sport-related blunt trauma to the chest
  • Affected individuals usually die before reaching the hospital.
  • Can manifest as arrhythmias, commotio cordis, and sudden death
Injuries to the aorta and great vessels
  • Very rare (0.06%–0.1%)
  • Most common site is the aortic isthmus.
  • Widening of the mediastinal contour on chest X-ray
Esophageal injury
  • 0.1% of blunt trauma cases
  • Associated with other mediastinal injuries
  • Produce chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain or epigastric pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Recognized by pneumomediastinum or pneumoperitoneum in diagnostic imaging (pneumomediastinum in 10% of cases of blunt chest trauma Blunt chest trauma Blunt chest trauma is a non-penetrating traumatic injury to the thoracic cavity. Thoracic traumatic injuries are classified according to the mechanism of injury as blunt or penetrating injuries. Different structures can be injured including the chest wall (ribs, sternum), lungs, heart, major blood vessels, and the esophagus. Blunt Chest Trauma)
Diaphragmatic injury
  • May be accompanied by phrenic nerve paralysis, liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver and spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen injury, and respiratory distress
  • Bowel sounds in the chest may be heard.
Traumatic asphyxia
  • Rare
  • High-speed motor vehicle accidents, crush injuries to the head and torso
  • Occurs due to flexibility of 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
  • Intrathoracic pressure increases with compressive force from the abdomen against a closed glottis.
  • Petechiae appear in the oral mucosa with edema and cyanosis.
Tracheobronchial injury
  • Due to rapid deceleration, crush injuries, or force to the chest against a closed glottis
  • Most commonly expressed as mediastinal air, pneumothoraces, and subcutaneous emphysema
  • May be lethal in ⅓ of cases
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
Table: Life-threatening injuries to be considered during the primary survey of thoracic trauma
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
  • Tension pneumothorax
  • Open pneumothorax
  • Flail thorax
  • Pulmonary contusion
  • Massive 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
  • Cardiac contusion
  • Cardiac tamponade
  • Aortic disruption

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

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

  1. Kuo, D.Z., Houtrow, A.J. (2016). Recognition and management of medical complexity. Pediatrics, 138, 1. https://search.proquest.com/docview/1846002393
  2. 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
  3. 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
  4. 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

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