1405CHAPTER 119 Pediatric Thoracic Trauma Traumatic Asphyxia Traumatic asphyxia is a rare condition that can occur after severe compression to the chest or abdomen, most commonly after a motor vehicle[.]
CHAPTER 119 Pediatric Thoracic Trauma 1405 Traumatic Asphyxia Traumatic asphyxia is a rare condition that can occur after severe compression to the chest or abdomen, most commonly after a motor vehicle accident During a compressive force, patients perform a Valsalva maneuver (holding their breath against a closed glottis, thereby increasing intrathoracic pressure) This increased intrathoracic pressure causes increased pressure in the innominate and jugular veins, leading to congestion in the venules and capillaries of the cervicofacial region Sequelae include facial edema, cyanosis, conjunctival hemorrhage, face and chest petechiae, periorbital edema, respiratory distress, and altered mental status Neurologic manifestations may include agitation, loss of consciousness, confusion, seizures, transient visual changes, or blindness Treatment is typically supportive and includes observation for airway compromise if oropharyngeal edema is severe The majority of cases have a good prognosis and, although dramatic in presentation, the prognosis is good—with most symptoms completely resolving.58 Cardiac Injuries Cardiac injuries are rare in the pediatric population but are associated with a high mortality (40%) Most injuries are cardiac contusions (59%) after blunt trauma, but lacerations also occur (36%), most commonly after penetrating trauma Cardiac injuries are associated with lung injury (46%), hemopneumothorax (37%), and rib fractures (26%) Cardiac arrest is rare (4%).59 Commotio cordis is a rare, but life-threatening, phenomenon seen in children after a blow to the chest It leads to sudden cardiac arrest and is characterized by the absence of structural heart disease, pulmonary contusion, coronary artery abnormalities, and organic conduction system pathology It occurs after a direct blow over the heart precisely timed to the repolarization phase of the cardiac cycle (15–30 ms before the T-wave peak) Ventricular tachydysrhythmia ensues and should be treated with an automatic external defibrillator in accordance with Advanced Cardiac Life Support (ACLS) guidelines for the dysrhythmia It is commonly seen in young males in conjunction with sports-related injury, mainly basketball and football Much attention has recently been focused on chest protectors and the availability of automatic external defibrillators at athletic events.60 Cardiac contusion with compromised cardiac function is very rare in children but can be caused by blunt trauma Children with bruising over the sternum or evidence of fracture should be further evaluated Although no consensus pediatric guidelines exist to guide diagnostic approach, screening electrocardiography is typically performed Clinical suspicion must dictate whether further workup is performed, including cardiac enzymes, admission with telemetry, or echocardiography Cardiac troponin is not found in skeletal muscle, and should be measured, as total creatine kinase (CK) and CK-myocardial bound may be elevated from other muscle injury or inflammation Transesophageal echocardiogram is the most sensitive indicator of cardiac injury However, it requires sedation and is not free from complications The most common manifestations are dysrhythmias and hypotension from decreased cardiac output Affected patients should be considered for ICU admission with telemetry, IV access, oxygen, and analgesics Dobutamine can be used to maintain cardiac output provided that the patient has been appropriately fluid resuscitated Extreme injuries have been managed with intraaortic balloon pump or extracorporeal membrane oxygenation.61 Cardiac rupture following blunt impact is almost universally fatal, often before arrival to the hospital Most penetrating cardiac injuries occur in male patients in conjunction with stab wounds Survival after cardiac laceration is less than 30% Of those patients who survive to reach the trauma bay, mortality rates for a wound to the right atrium, left ventricle, right ventricle, and multiple chambers are 83%, 79%, 57%, and 100%, respectively.62 Survival from stab wounds is much higher than from gunshot wounds, as a blast injury tends to be widely destructive to the cardiac parenchyma.63 Cardiac tamponade is an egress of blood through the cardiac wound into the pericardial space, with subsequent diastolic failure and obstructive shock Any evidence of penetrating injury to the “cardiac box” (superior and inferior borders are the sternal notch and xiphoid; lateral borders are nipples bilaterally) should raise the possibility of cardiac laceration and tamponade Tamponade should also be suspected in an unstable patient with equal breath sounds and normal chest radiograph The Beck triad includes muffled heart sounds, distended neck veins, and hypotension This triad occurs in 90% of cases of cardiac tamponade However, if the patient has lost a significant amount of blood from other sources, the neck veins may not be distended, and it is often difficult to auscultate heart sounds over the noise of the trauma bay A high index of suspicion should be maintained and any penetrating injury to the chest must be considered a cardiac injury until proven otherwise Ultrasound, if immediately available, can quickly determine the presence of a pericardial effusion Patients with concern for tamponade and loss of vital signs should undergo resuscitative left posterolateral thoracotomy in the emergency department Emergent pericardiocentesis has been abandoned as a management strategy as the blood in the pericardial sac may clot, rendering a false-negative result The most frequent complications after cardiac repair include hypothermia, acidosis, and coagulopathy Cardiac dysrhythmias can be seen in patients after profound hypothermia.63 Aortic injury in children surviving to emergency department evaluation is exceedingly rare Mechanisms of injury include high-energy deceleration, compression, or crush of the torso Chest radiograph findings with blunt aortic injury commonly include prominent aortic knob, wide paratracheal stripe, or widened mediastinum on chest radiograph Stable patients with a high-risk mechanism of injury and these chest radiograph findings should undergo emergent CT angiography examination, which has evolved as the gold standard for aortic injury diagnosis over aortography (Fig 119.2) Esophageal Injury The esophagus is well protected in the center of the chest and is rarely injured, even in penetrating trauma High-energy blunt trauma may create high intragastric pressure that can rupture the lower esophagus The cervical esophagus is more commonly injured during endoscopic procedures; caustic ingestions are another major cause of perforations in children under the age of years Pneumomediastinum or pleural effusion after trauma should prompt an investigation for esophageal injury CT scan has limited sensitivity; diagnosis may be made with water-soluble contrast esophagography and a negative result may be confirmed with cautious upper gastrointestinal endoscopy Certain small perforations in stable patients may be amenable to endoscopic treatment, including tissue sealant or clip application Unrecognized injury may proceed to mediastinitis and sepsis Treatment 1406 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma B A • Fig 119.2 (A) Chest radiograph demonstrating a prominent aortic knob, widened mediastinum, and right-sided tracheal deviation after blunt trauma These findings are concerning for an aortic injury. (B) Subsequent computed tomography scan showing an aortic tear causing a pseudoaneurysm in children differs from that of adults in that most adults require immediate primary repair In the majority of cases, children are better served by a nonoperative approach based on adequate drainage of the affected space, with parenteral nutrition and antibiotics.64 Some patients with small perforations and no evidence of infection may not require drainage procedures When output from any drains is bland in character and decreasing in volume, a contrast esophagram should be obtained Feeding should be resumed only after confirmation that the esophageal injury has completely healed, typically within to weeks.65 Chylothorax Traumatic chylothorax is rare in children but usually seen after blunt trauma It is associated with hyperextension of the spine and fractures of the spine or posterior ribs Injury to the thoracic duct should be suspected when a pleural effusion is present on chest radiograph and an esophageal injury has been properly excluded from the diagnosis Drainage of the fluid reveals a milky white substance with triglyceride levels greater than 110 mg/dL, the presence of chylomicrons, low cholesterol levels, and a predominance of lymphocytes Most chylothoraces can be managed nonoperatively with chest tube drainage and either medium-chain fatty acid diet or total parenteral nutrition Somatostatin and octreotide have been used to hasten closure of the injury If the daily loss of chylous fluid exceeds 100 mL per year of age or if the defect fails to close with nonoperative management, then surgical closure is indicated.66 Children can become leukopenic and prone to infection if the chylous drainage is excessive and sustained They can also become malnourished owing to excessive nutrient losses through chylomicron wasting and white cell turnover Diaphragmatic Injury Diaphragmatic rupture is a rare event in the pediatric population Falls from heights and MVCs are common mechanisms, but diaphragmatic injury also occurs with penetrating trauma Differences in the distribution of blunt and penetrating trauma will vary with geographic location and the prevalence of violence among children When it does occur, it is most commonly associated with other injuries, for example, of the small bowel In many cases, the diagnosis can be made on chest radiograph Pleural effusion, elevated hemidiaphragm, lower lobe collapse, and positioning of the nasogastric tube in the thorax are all findings that should prompt further investigation However, small diaphragmatic injuries from stab or bullet wounds that are not evident on chest radiograph may be very difficult to diagnose radiographically, including with CT scan, which is insensitive to detect this injury Diagnostic laparoscopy is typically required when there is suspicion of a diaphragmatic injury based on missile trajectory but with negative CT Left-sided rupture after blunt trauma is more common, as the liver serves to absorb the energy on the right side Associated injuries are common and can include any organ Delay in diagnosis can lead to herniation and bowel incarceration At any laparotomy for trauma, both sides of the diaphragm should be carefully inspected Repair of the diaphragm can be approached either via laparoscopy (for small defects), laparotomy, or thoracotomy It is often approached via laparotomy in the trauma setting as this allows for exploration of the other abdominal organs Pneumonia is the most common postoperative complication after diaphragm repair.67–69 Conclusions Thoracic trauma in the pediatric population is a major source of morbidity and mortality Prompt intervention is required for lifethreatening injuries and should follow the principles of managing airway, breathing, and circulation Lung and chest wall injuries are the most common injuries encountered and can primarily be managed with nonoperative intervention Tube thoracostomy is the most common intervention performed for thoracic trauma Injuries to other organs in the chest are rare but may be serious CHAPTER 119 Pediatric Thoracic Trauma and require a high clinical index of suspicion to avoid missing injuries that evade conventional imaging—especially those to the heart, esophagus, and diaphragm Prompt resuscitation and intervention minimize morbidity and mortality Key References Agnew AM, Schafman M, Moorhouse K, White SE, Kang YS The effect of age on the structural properties of human ribs J Mech Behav Biomed Mater 2015;41:302-314 Armstrong LB, Mooney DP Pneumatoceles in pediatric blunt trauma: common and benign J Pediatr Surg 2018;53:1310-1312 Bauman ZM, Kulvatunyou N, Joseph B, et al A prospective study of 7-year experience using percutaneous 14-French pigtail catheters for traumatic hemothorax/hemopneumothorax at a level-1 trauma center: size still does not matter World J Surg 2018;42:107-113 Brody AS, Frush DP, Huda W, Brent RL, American Academy of Pediatrics Section on, R Radiation risk to children from computed tomography Pediatrics 2007;120:677-682 Darling SE, Done SL, Friedman SD, Feldman KW Frequency of intrathoracic injuries in children younger than years with rib fractures Pediatr Radiol 2014;44:1230-1236 Duff JP, Topjian A, Berg MD, et al 2018 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2018;138:e731-e739 Holmes JF, Kelley KM, Wootton-Gorges SL, et al Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial JAMA 2017;317:2290-2296 1407 Kamyszek RW, Leraas HJ, Reed C, et al Massive transfusion in the pediatric population: a systematic review and summary of best-evidence practice strategies J Trauma Acute Care Surg 2019;86(4):744-754 Kaptein YE, Talving P, Konstantinidis A, et al Epidemiology of pediatric cardiac injuries: a National Trauma Data Bank analysis J Pediatr Surg 2011;46:1564-1571 Kessel B, Dagan J, Swaid F, et al Rib fractures: comparison of associated injuries between pediatric and adult population Am J Surg 2014;208:831-834 Notrica DM, Garcia-Filon P, Moore FO, et al Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study J Pediatr Surg 2012;47:467-472 Peclet MH, Newman KD, Eichelberger MR, et al Thoracic trauma in children: an indicator of increased mortality J Pediatr Surg 190;25: 961-965; discussion 965-966 Ramgopal S, Shaffiey SA, Conti KA Pediatric sternal fractures from a Level trauma center J Pediatr Surg 2019;54(8):1628-1631 Roberts JS, Bratton SL, Brogan TV Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients Chest 1998;114:1116-1121 Scaife ER, Rollins MD, Barnhart DC, et al The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation J Pediatr Surg 2013;48:1377-1383 Tracy ET, Englum BR, Barbas AS, et al Pediatric injury patterns by year of age J Pediatr Surg 2013;48:1384-1388 Yanchar NL, Woo K, Brennan M, et al Chest x-ray as a screening tool for blunt thoracic trauma in children J Trauma Acute Care Surg 2013;75:613-619 The full reference list for this chapter is available at ExpertConsult.com e1 References van As AB, Manganyi R, Brooks A Treatment of thoracic trauma in children: literature review, Red Cross War Memorial Children’s Hospital data analysis, and guidelines for management Eur J Pediatr Surg 2013;23:434-443 Mollberg NM, Tabachnick D, Lin FJ, et al Age-associated impact on presentation and outcome for penetrating thoracic trauma in the adult and pediatric patient populations J Trauma Acute Care Surg 2014;76:273-277; discussion 277-278 Sartorelli KH, Vane DW The diagnosis and management of children with blunt injury of the chest Semin Pediatr 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51:504-506 67 Peer SM, Devaraddeppa PM, Buggi S Traumatic diaphragmatic hernia-our experience Int J Surg (London, England) 2009;7:547549 68 Okur MH, Uygun I, Arslan MS, et al Traumatic diaphragmatic rupture in children J Pediatr Surg 2014;49:420-423 69 Ramos CT, Koplewitz BZ, Babyn PS, Manson PS, Ein SH What have we learned about traumatic diaphragmatic hernias in children? J Pediatr Surg 2000;35:601-604 ... be resumed only after confirmation that the esophageal injury has completely healed, typically within to weeks.65 Chylothorax Traumatic chylothorax is rare in children but usually seen after blunt... difficult to diagnose radiographically, including with CT scan, which is insensitive to detect this injury Diagnostic laparoscopy is typically required when there is suspicion of a diaphragmatic... defects), laparotomy, or thoracotomy It is often approached via laparotomy in the trauma setting as this allows for exploration of the other abdominal organs Pneumonia is the most common postoperative