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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 Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology vehicle accidents and falls. Chest trauma rarely occurs in isolation and is often associated with polytrauma Polytrauma Multitrauma occurs when 2 or more traumatic injuries occur in at least 2 areas of the body. A systematic management approach is necessary for individuals who have undergone trauma to maximize outcomes and reduce the risk of undiscovered injuries. Multitrauma. 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.

Last updated: 28 Oct, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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 Polytrauma Multitrauma occurs when 2 or more traumatic injuries occur in at least 2 areas of the body. A systematic management approach is necessary for individuals who have undergone trauma to maximize outcomes and reduce the risk of undiscovered injuries. Multitrauma
  • Majority due to motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology 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 Gunshot wounds Disruption of structural continuity of the body as a result of the discharge of firearms. Penetrating Chest Injury
  • Overall mortality Mortality All deaths reported in a given population. Measures of Health Status: 15%–26%

Pathophysiology and anatomy

The thoracic region Thoracic region Spinal Cord: Anatomy of a child is more compliant compared to that of adults:

  • Flexible ribs Ribs A set of twelve curved bones which connect to the vertebral column posteriorly, and terminate anteriorly as costal cartilage. Together, they form a protective cage around the internal thoracic organs. Chest Wall: Anatomy:
    • Due to a lesser degree of ossification Ossification The process of bone formation. Histogenesis of bone including ossification. Bones: Development and 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: Anatomy is more mobile:
    • More drastic visceral displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms
    • Loss of preload Preload Cardiac Mechanics 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
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
  • Less common
  • Described as a chest “white-out” in X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests
  • 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 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 Ventilation The total volume of gas inspired or expired per unit of time, usually measured in liters per minute. Ventilation: Mechanics of Breathing/perfusion mismatch
  • 2 mechanisms: compression Compression Blunt Chest Trauma or tearing, and severe displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms
  • Alveolar bleeding produces hepatization.
  • Consolidated area on chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests (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 Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) injury or cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) contusion
  • Seen in sport-related blunt trauma to the chest
  • Affected individuals usually die before reaching the hospital.
  • Can manifest as arrhythmias, commotio cordis Commotio cordis A sudden cardiac arrhythmia (e.g., ventricular fibrillation) caused by a blunt, non-penetrating impact to the precordial region of chest wall. Commotio cordis often results in sudden death without prompt cardiopulmonary defibrillation. Blunt Chest Trauma, and sudden death
Injuries to the aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy and great vessels
  • Very rare (0.06%–0.1%)
  • Most common site is the aortic isthmus Isthmus Uterus, Cervix, and Fallopian Tubes: Anatomy.
  • Widening of the mediastinal contour on chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests
Esophageal injury
  • 0.1% of blunt trauma cases
  • Associated with other mediastinal injuries
  • Produce chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or epigastric pain Epigastric pain Mallory-Weiss Syndrome (Mallory-Weiss Tear)
  • Recognized by pneumomediastinum Pneumomediastinum Mediastinitis or pneumoperitoneum Pneumoperitoneum A condition with trapped gas or air in the peritoneal cavity, usually secondary to perforation of the internal organs such as the lung and the gastrointestinal tract, or to recent surgery. Pneumoperitoneum may be purposely introduced to aid radiological examination. Perforated Viscus in diagnostic imaging ( pneumomediastinum Pneumomediastinum Mediastinitis 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 Phrenic nerve The motor nerve of the diaphragm. The phrenic nerve fibers originate in the cervical spinal column (mostly C4) and travel through the cervical plexus to the diaphragm. Diaphragm: Anatomy 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: Anatomy 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: Anatomy injury, and respiratory distress
  • Bowel sounds in the chest may be heard.
Traumatic asphyxia Asphyxia A pathological condition caused by lack of oxygen, manifested in impending or actual cessation of life. Drowning
  • Rare
  • High-speed motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology 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: Anatomy
  • Intrathoracic pressure increases with compressive force from the abdomen against a closed glottis Glottis The vocal apparatus of the larynx, situated in the middle section of the larynx. Glottis consists of the vocal folds and an opening (rima glottidis) between the folds. Larynx: Anatomy.
  • Petechiae Petechiae Primary Skin Lesions appear in the oral mucosa Oral mucosa Lining of the oral cavity, including mucosa on the gums; the palate; the lip; the cheek; floor of the mouth; and other structures. The mucosa is generally a nonkeratinized stratified squamous epithelium covering muscle, bone, or glands but can show varying degree of keratinization at specific locations. Stomatitis with edema and cyanosis Cyanosis A bluish or purplish discoloration of the skin and mucous membranes due to an increase in the amount of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule. Pulmonary Examination.
Tracheobronchial injury
  • Due to rapid deceleration Deceleration A decrease in the rate of speed. Blunt Chest Trauma, crush injuries, or force to the chest against a closed glottis Glottis The vocal apparatus of the larynx, situated in the middle section of the larynx. Glottis consists of the vocal folds and an opening (rima glottidis) between the folds. Larynx: Anatomy
  • Most commonly expressed as mediastinal air, pneumothoraces, and subcutaneous emphysema Subcutaneous emphysema Presence of air or gas in the subcutaneous tissues of the body. Mallory-Weiss Syndrome (Mallory-Weiss Tear)
  • May be lethal in ⅓ of cases
Penetrating trauma Gunshot wounds are an increasingly common cause.

Assessment

Primary survey

  • Airway Airway ABCDE Assessment:
    • 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: Anatomy for breathing.
    • In cases of pneumothorax, 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:
  • Disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment:
    • Assess the level of alertness.
    • GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma < 8 is an indication for emergent intubation Intubation Peritonsillar Abscess.
  • Exposure Exposure ABCDE Assessment:
    • 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 Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment and perfusion of the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification
    • Helpful in assessing mental status
Table: Life-threatening injuries to be considered during the primary survey of thoracic trauma
A B C
Airway Airway ABCDE Assessment obstruction or tracheobronchial rupture
  • Massive hemothorax
  • Cardiac contusion
  • Cardiac tamponade Cardiac tamponade Compression of the heart by accumulated fluid (pericardial effusion) or blood (hemopericardium) in the pericardium surrounding the heart. The affected cardiac functions and cardiac output can range from minimal to total hemodynamic collapse. Pericardial Effusion and Cardiac Tamponade
  • Aortic disruption

Secondary survey Secondary Survey ABCDE Assessment or evaluation

Workup

  • Diagnostic imaging:
    • Ultrasound (eFAST) in cases of hemodynamic instability
    • Chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests: to determine rib fractures Rib fractures Fractures of any of the ribs. Flail Chest, areas of consolidation Consolidation Pulmonary Function Tests (lung contusion), pneumothorax, and hemothorax
    • CT: to determine aortic disruption and hemothorax
    • Bronchoscopy Bronchoscopy Endoscopic examination, therapy or surgery of the bronchi. Laryngomalacia and Tracheomalacia 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: Anatomy
    • 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: Anatomy
  • Laboratory assessments: troponin levels to rule out blunt cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) 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. Electrocardiogram (ECG): to check for arrhythmias

Management

Management depends on the injury (rapid initiation of high- quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement CPR CPR The artificial substitution of heart and lung action as indicated for heart arrest resulting from electric shock, drowning, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation and closed-chest cardiac massage. Cardiac Arrest if the individual fails the airway, breathing, circulation Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment (ABC) assessment).

Supportive management

  • Monitoring of vital signs
  • Maintain airway: Intubate if necessary.
  • Maintain oxygenation:
    • Supplemental O2
    • Positive pressure ventilation Positive pressure ventilation Application of positive pressure to the inspiratory phase when the patient has an artificial airway in place and is connected to a ventilator. Flail Chest, if necessary
  • Maintain blood pressure/perfusion:

Life-threatening injuries

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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