Thoracic trauma

OVERVIEW: What every practitioner needs to know

Thoracic Injuries occur in 8% of children who have sustained major trauma, with motor vehicle crashes and accidental injury (e.g., falls) accounting for most. Penetrating trauma comprises a small but growing portion of pediatric chest trauma. Although the pliability of the pediatric chest wall predisposes children to intrathoracic injury, life-threatening chest injury requiring emergent operative management is rare. On the other hand, two-thirds of children with chest injuries have concomitant, non-thoracic injuries.

Are you sure your patient has thoractic trauma? What are the typical findings for this disease?

Common presenting signs of thoracic trauma:

All children with major mechanism blunt trauma (e.g., high-speed motor vehicle crash) or penetrating chest trauma should be evaluated for signs of intrathoracic injury.

Common signs: Visible external evidence of chest trauma, including bruising, laceration, or stab wound; Tenderness to palpation; Respiratory distress or absent/diminished breath sounds.
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Other signs to look for: Subcutaneous emphysema; Hematoma at the base of the neck or axilla; Mobile rib segments; Tracheal shift.

The absence of physical exam findings or of early symptoms does not exclude major injury, and work-up should proceed according to the advanced trauma life support (ATLS) guidelines published by the American College of Surgeons.

What type of thoracic injuries are most common in blunt thoracic trauma?

Pneumohemothorax (39%-50%)
Pulmonary contusion (48%)
Cardiac contusion (3%)

Less common injuries seen with blunt thoracic trauma:

Rib fracture
Pulmonary laceration
Sternum fracture
Diaphragm rupture
Tracheobronchial injury
Great vessel injury
Cardiac laceration or rupture
Commotio cordis
Traumatic asphyxiation

What other disease/condition shares some of these symptoms?

Atypical patterns of injury (e.g., posterior rib fractures in an infant) or incoherent reported mechanism of injury (i.e., the story does not match the injury) obligate consideration of non-accidental trauma. In toddlers and infants, approximately two-thirds of rib fractures result from non-accidental trauma. Therefore, any child less than the age of three years suffering a rib fracture should be routinely evaluated for non-accidental trauma. This should be done in collaboration with a child abuse prevention team.

What caused this disease to develop at this time?

Patterns of injury correlate to the age of the patient and the mechanism of injury, e.g., penetrating injury is more common in older children and is more likely to cause pulmonary laceration, cardiac or major vascular injury. The pliability of the pediatric chest wall confers relative protection from rib fractures (occurring in <2% of injured children), but predisposes the younger child to injury to underlying organs (i.e., the lungs and mediastinal structures). Rib fractures suggest major impacting force, and suspicion for underlying intrathoracic injury should be very high in any child with rib fractures.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

Complete Blood Count, Metabolic Profile, Prothrombin Time and Partial Thromboplastin Time: These should be obtained for all patients with major trauma. However, these may all be normal in the acute setting, and emergent treatment will seldom be guided by these studies.

Artierial Blood Gases and Serum Lactate concentration: A grossly abnormal pH, base deficit, or serum lactate concentration helps to assess the degree of shock. Unexplained abnormalities of PO2, PCO2, pH or base deficit should prompt further evaluation.

Electrocardiogram (EKG): If cardiac contusion is suspected (e.g., with sternal fracture) the initial EKG in the emergency department guides management. If it is normal, no further studies are required. An abnormal EKG should prompt continuous cardiac monitoring (i.e., telemetry) for at least 24 hours. Any patient serial troponin evaluations have no role in the diagnosis or management of cardiac contusion in children.

Would imaging studies be helpful? If so, which ones?

Chest X-Ray: All patients with major mechanism blunt trauma or penetrating chest trauma should have a portable chest X-ray as soon as possible. The image may show pneumothorax, hemothorax, widened mediastinum, tracheal deviation, or fractures (rib, clavicle, spine, or scapula).

Treatment of patients with signs/symptoms of life-threatening tension hemo/pneumothorax should never be delayed awaiting radiographic confirmation.

High-risk patients with normal inital chest X-ray should have a repeat examination 6 hours after admission, unless a chest CT has been obtained. Also, any patient who has undergone an intervention (intubation, central venous catheter placement, tube thoracostomy) should have a repeat chest X-ray immediately thereafter.

Chest CT: Abnormal-appearing mediastinum on chest X-ray should prompt a chest CT with intravenous contrast to rule out great-vessel injury in patients who are stable. CT evaluation should never delay treatment of life-threatening injuries. Due to the risk of radiation exposure, chest CT should be used judiciously.

Ultrasound: The focused assessment with sonography for trauma (FAST) has become standard in trauma care. The FAST exam includes evaluation of the pericardium for effusion. Experienced physicians can also use ultrasound to detect pneumothorax.

Confirming the diagnosis

Decision pathways and algorithms for thoracic trauma:

Evaluation and treatment of any trauma patient should follow ATLS guidelines, with priority given to the primary survey and stabilization of the ‘ABCs’ of Airway, Breathing, and Circulation. Unlike other diseases, with trauma, evaluation and treatment often must proceed concurrently.

Evaluation of the chest should start with a physical examination (primary and secondary survey) proceeding to a portable chest X-ray. CT scan of the chest is indicated in specific situations as noted above. It is absolutely mandatory that treatment of unstable patients with suspected tension pneumothorax or hemothorax not be delayed until radiographic confirmation of the diagnosis.

Special consideration must be given to the unique aspects of pediatric anatomy when assessing findings. For example, the ‘seat belt sign’ (linear bruising in areas in contact with a seat belt) may be absent in children in car seats. Remember also that hypotension may be a sign of massive hemothorax, tension pneumothorax, or pericardial tamponade.

If you are able to confirm that the patient has thoracic trauma, what treatment should be initiated?

Management of specific thoracic injuries:

The majority of thoracic injuries are managed expectantly or with supportive care only.

Pulmonary Contusion:

Supportive care: Careful fluid management and lung-injury prevention ventilatory strategies (for intubated patients) are paramount.
Concomitant injuries are common in children with pulmonary contusion.

Pneumothorax:

Tube thoracostomy: If pneumothorax is suspected in an unstable patient, immediate tube thoracostomy is required. Treatment of tension pneumothorax (or tension hemothorax) should never be delayed until the diagnosis is confirmed radiographically. Additionally, the most important step is incision of the chest wall, which will decompress the tension.
Needle decompression (2nd intercostal space, midclavicular line) is seldom useful, except in cases where the physician suspects tension pneumothorax with hemodynamic compromise. Needle decompression may be lifesaving in this setting. If used, however, care must be taken to avoid vascular or lung injury.
Expectant management: Some pneumothoraces do not require evacuation. These include small (<20%) asymptomatic pneumothoraces and ‘CT-only’ pneumothoraces. In these cases, a repeat chest X-ray should be obtained approximately 6 hours after the initial exam. If the pneumothorax is stable and asymptomatic, no chest tube is requred.

Hemothorax:

Tube Thoracostomy: If massive hemothorax is suspected in an unstable patient, immediate tube thoracostomy is required. Evacuation of a hemothorax may relieve compressive symptoms, and aids in evaluation of the patient. The amount of blood on initial insertion, as well as the ongoing output, guide the decision to perform urgent exploratory thoracotomy.
Thoracotomy: Indications for thoracotomy include initial bloody output of >20%-30% of estimated blood volume OR ongoing output of 2-3 cc/kg/hr for 3 consecutive hours. For older children and adolescents, non-weight based criteria may be used. These are an initial chest tube output of >1000 ml (penetrating) or >1500 ml (blunt) OR an ongoing output of >200 ml/hr for 3 consecutive hours.
Expectant management: The majority of hemothoraces are small and do not require drainage.
Clotted hemothorax: A large hemothorax that is found on repeat chest X-ray to be incompletely drained by two chest tubes mandates open or thoracoscopic evacuation to avoid hemofibrothorax and lung entrapment.

What are the adverse effects associated with each treatment option?

Tube thoracostomy is often a necessary and lifesaving procedure for hemothorax and pneumothorax. However, extreme care should be taken to avoid contamination, as a breach of sterile technique may predispose the patient to empyema. This will require the following:

Control the trauma treatment area (other procedures may have to be stopped during chest tube placement)
Prep and drape adequately to protect the chest tube from exposure to non-sterile linens, skin, etc.
Make sure you have a competent assistant to provide materials and instruments in a sterile manner.

Furthermore, chest tubes should be removed as soon as there is no ongoing therapeutic benefit; therefore, evaluation for potential removal must take place daily.

What are the possible outcomes of thoracic trauma?

Mortality and morbidity of thoracic injury depends to some extent on the pattern and extent of injury to the chest, but, perhaps more significantly, outcomes depend on concomitant injuries.

Counseling of parents about the prognosis of their multiply-injured child should be tailored to the specific constellation of injuries present. Isolated chest injury mortality is approximately 5%. Mortality increases to approximately 25% with one additional injury and up to 40% with two or more non-chest injuries. Mortality may be as high as 70% when children have chest injuries and traumatic brain injury. However, thoracic injuries are rarely the cause of death in blunt poly-trauma patients with thoracic injuries.

Trauma-related systemic inflammatory response and multiple organ failure (MOF) are rare in children. MOF occurs in approximately 3% of severely injured poly-trauma victims under the age of 16, compared with 25% in patients over 16 years of age (including adults). The immunological and physiological reasons for this difference are largely obscure.

What causes this disease and how frequent is it?

Epidemiology of thoracic trauma:

Trauma is the most common cause of morbidity and mortality among children. Most mortality in pediatric trauma is due to head injury, but thoracic injury is the second most common cause of mortality in injured pediatric patients.

Motor vehicle crashes are the leading cause of death in children aged 1 to 19 years, and are the cause of most thoracic injuries. The home is the second most common location for pediatric trauma.

Age and gender are the most important determinants of injury mechanism, pattern, and prognosis. Chest trauma in infants and toddlers is most commonly the result of abuse or motor vehicle crashes. When evaluating a young child in the emergency department, physicians should remember that over 50% of rib fractures in children less than 3 years old are the result of non-accidental trauma. School-aged children are more likely to be injured as pedestrians, and children aged 10 to 17 tend to sustain chest injuries while on bicycles or skateboards. In the later teenage years, most injuries are related to risk-taking behaviors, whether recreational (e.g., extreme sports) or violent (i.e., assault or suicide), and boys are more likely to participate in these activities than girls of similar age. Penetrating trauma to the chest occurs almost exclusively in teenagers.

Risk factors for thoracic trauma:

Trauma patterns are dictated by age-related exposures. For example, non-accidental trauma occurs primarily in infants and toddlers; falls and bicycle accidents are more common in school-age children; and motor vehicle crashes and penetrating trauma are more common in adolescents.

Likewise, the changing anatomy and physiology, from birth to adolescence, affects the patterns of thoracic injury. For example, young children have extremely pliable ribs and are therefore protected from rib fractures in all but major trauma. Also, great vessel injury, which is exceedingly rare in younger children, should be considered in older teenage children with major mechanism trauma.

What complications might you expect from the disease or treatment of the disease?

In the setting of a retained hemothorax (i.e., inadequate drainage), patients are predisposed to empyema. With pulmonary laceration, children can develop persistent air leaks, requiring prolonged tube thoracostomy drainage.

How can thoracic trauma be prevented?

Trauma prevention is a difficult and multifactorial matter. However, parents of children should be counseled routinely about the importance of pro-active measures to avoid major injury, including size- and age-appropriate car restraints. Inspection of the home for fall risks should also be recommended, with attention paid to unsafe windows and balconies.

Ongoing controversies regarding etiology, diagnosis, treatment

Trauma protocols, including the ATLS protocols, are constantly under review and are updated regularly. Physicians who will care for injured children should remain abreast of the most current ATLS protocols.

One area of controversy in pediatric trauma is the role of CT in evaluation of chest injuries. Because the incidence of great vessel injury is exceedingly low in children under 15 years old, in the absence of chest film findings, we suggest avoiding the radiation of a CT scan unless there is specific concern for great vessel injury. However, the actual long-term risk of the additional radiation exposure from a CT scan is an area of ongoing investigation. As more is learned, criteria for CT scan of the chest in traumatized children may broaden or narrow.

What is the evidence?

“ATLS® for Doctors”. The Advanced Trauma Life Support (ATLS) manual, published by the American College of Surgeons, provides the definitive protocols of emergent care of the injured patient and should be regarded as essential reading for all physicians involved in the care of traumatized patients, including children. All children with thoracic trauma should be assessed and managed according to the ATLS guidelines. Although the ATLS program is not focused on pediatric trauma, the manual includes chapters on general thoracic trauma as well as on the care of the injured child.

Garcia, VF, Mooney, D, Ziegler, MM, Azizkhan, RG, Weber, TR. “Thoracic injuries”. Operative pediatric surgery. 2003. pp. 1115-24. This chapter provides a very helpful review of thoracic trauma from a pediatric surgery perspective. Whereas the ATLS guidelines focus on stabilization of the injured patient, this chapter is a good source for information regarding emergency room assessment, inpatient management, and operative care of children with chest trauma.

Feliciano, DV, Mattox, KL, Moore, EE. “Trauma”. 2008. The definitive text on care of the injured patient,
Trauma is the resource for comprehensive discussion of all areas of patient care related to injury, including operative and critical care management. There are several chapters related to thoracic trauma as well as a chapter detailing special considerations in the care of the injured child. This text is written with the trauma surgeon in mind, but it is a useful resource for all trauma providers, including critical care pediatricians and emergency room physicians.

Moore, MA, Wallace, ED, Westra, SJ. “Chest trauma in children: current imaging guidelines and techniques”. Radiol Clin North Am. vol. 49. 2011. pp. 949-68. This article discusses the current considerations of optimal diagnostic radiography and radiation exposure risks in pediatric trauma. The authors review the current literature related to radiological evaluation of children with chest injuries, and they suggest that CT scanning should be used sparingly and that pediatric protocols should be instituted to minimize radiation exposure when CT scan is deemed necessary. The authors also provide a concise overview of the epidemiology and physiology of pediatric chest trauma.

Dowd, MD, Keenan, HT, Bratton, SL. “Epidemiology and prevention of childhood injuries”. Crit Care Med. vol. 30. 2002. pp. S385-92. An excellent overview of the incidence and risk factors for trauma in the pediatric population, this review article also describes injury prevention strategies for trauma in general as well as specific injury types, such as motor vehicle crashes, bicycle accidents, etc.

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