Major thoracic trauma in children may be immediately life threatening because the injury strikes at the two primary systems: the oxygenator (lungs) and the pump (heart). Penetrating injuries may damage either of these organ systems in a child, but blunt trauma is a far more common cause of serious injuries in children.1 Penetrating injuries nearly always result from fractured and displaced ribs or clavicles, in contradistinction to the high frequency of external missile injuries in adults.2
Hypoxemia and hypotension following chest injuries allow little time for deliberation and consultation because the high metabolic needs of the young child must be continuously supplied by the cardiopulmonary system. Blunt thoracic trauma often causes more severe internal injuries than are initially apparent on external physical examination. The associated functional deficits may require immediate correction before very much is known about the mechanism of injury or the child's previous state of health.3 Physicians and paramedical personnel working in emergency medical systems must be prepared to act according to some preconceived plan for evaluation, triage, and resuscitation of a child with a significant chest injury. A single experienced physician must have primary responsibility for decision making in the evaluation and management of an injured child. Emergency treatment does not necessarily require the presence of a well-trained trauma physician or the ideal of a pediatric surgeon, but it does entail the utilization of physicians and nurses with experience in the management of life-threatening injuries.
Figure 1. Traumatic transection of the trachea with pneumomediastinum.
Figure 2A. Traumatic hemopneumothorax from a crush injury to the right chest.
Figure 2B. Resolutron after closely monitored closed thoracostomy drainage.
We have found it helpful to categorize children with major chest injuries into three arbitrary groups: those with chest injuries that are immediately life threatening, those with injuries that are serious but not immediately life threatening, and those with injuries that will not require intensive care and may not require hospitalization. These categories were chosen because they dictate a plan of management; therefore, they may be helpful in making decisions associated with the treatment of children with major chest injuries.
UFE-THREATENING chest injuries
Aspiration of foreign bodies, blood, or vomitus may be immediately life threatening and will require rapid re-establishment of a patent upper airway. Children who are unconscious from blunt head injuries often aspirate and may have obstructed airways. Direct trauma to the face and neck from blunt injuries in automobiles may result in occlusion of the airway. Finally, aspiration of foreign bodies, such as toys and coins, as well as the rarer aspiration of teeth from direct trauma, may cause airway obstruction.
Immediate exposure of the posterior pharynx with a laryngoscope of appropriate size will identify the cause of the upper-airway obstruction. The same maneuver will facilitate either endoscopy for suction of foreign material or insertion of an appropriate endotracheal tube to reestablish the airway. If the patient has a foreign body in the lower tracheobronchial tree, there will usually be an adequate passage for ventilation of one lung, to allow temporization until appropriate diagnostic bronchoscopy can be carried out under more controlled conditions.
A tracheostomy is rarely, if ever, indicated without initial placement of an endotracheal tube. Occasionally, direct trauma to the trachea or bronchus may result in a partial or complete transection and may require rapid endotracheal intubation and a lifesaving tracheostomy. Figure 1 illustrates transection of the trachea in a 12-year-old boy who was struck across the neck by a telephone cable when he ran into it on his motorcycle. When seen in the emergency room, he had complete airway obstruction, but this responded to oral-tracheal intubation. Following stabilization, neck exploration revealed complete transection of the trachea, which ultimately required a tracheostomy.
Massive, continuing intrathoracic hemorrhage may result from blunt and penetrating injuries to major vessels and occasionally to the lung parenchyma itself. Once a continuing hemothorax is recognized, a thoracotomy tube should be inserted promptly and the drainage carefully monitored. Persistent drainage of significant quantities of blood is an indication for emergency surgical exploration (Figure 2).
Major arteries and veins - and, in rare cases, the heart itself - may be injured by fractured ribs or clavicles or occasionally by blunt trauma to the sternum. Figure 3 shows a dramatic example of a ruptured right atrium associated with blunt trauma to the anterior chest. On initial examination, this patient had all the classic signs of pericardial tamponade: distended neck veins, hypotension, and an enlarged, quiet heart on fluoroscopy, with suppressed heart sounds.
Patients require careful monitoring of central venous pressure as well as other vital signs. We have avoided using the percutaneous subclavian catheter technique for the monitoring of central venous pressure in young children because of the high incidence of associated pneumothorax and difficulties in placement of the catheter. Instead, we prefer a direct cutdown on the external jugular vein, with placement of a small Silastic catheter via this vessel into the right atrium. Such patients should also have a urethral catheter inserted into the urinary bladder, to permit decompression and allow monitoring of urinary output.
Figure 3A. Anterior chest compression injury with rupture of the right atrium (immediate postoperative appearance).
Figure 3B. Residual pleural scar from thoracostomy tube in the left hemithorax and normal cardiac configuration three weeks after surgery.
SERIOUS CHEST INJURIES THAT ARE NOT IMMEDIATELY LIFE THREATENING
This type of chest trauma is most commonly seen in blunt injuries, which may affect various systems in young children. An example is multiple rib fractures with a pneumothorax or a small hemopneumothorax in association with peripheral limb fractures. A hemopneumothorax is best treated by closed thoracostomy drainage and frequent evaluation of respiratory function, including sequential measurement of arterial pC\ and pCCV These children must be evaluated rapidly and then managed in a pediatric intensive-care unit. Since many patients have associated parenchymal pulmonary contusion and even intrapulmonary hematoma, appropriate broad-spectrum antibiotics should be used to decrease the chances of secondary infection. A pulmonary contusion in a child, requiring hospitalization and support, is illustrated in Figure 4.
Figure 4A. Pulmonary contusion in the right lung requiring positive-pressure mechanical ventilation.
Figure 4B. Resolution of pulmonary contusion after five days.
A flail chest due to multiple rib fractures is rarely seen in early childhood because of the elastic nature of the chest wall and the high proportion of cartilage present in the ribs of young children. Nevertheless, it does occur and will respond to positivepressure ventilation through an endotracheal tube. In the few cases in which tracheostomy is necessary, the special surgical technique of tracheostomy in children should be used and plastic tracheostomy tubes should be selected so as to avoid the secondary trauma to the tracheal wall that may result from metal tracheostomy tubes attached to ventilators.
Traumatic asphyxia is commonly seen in children and is included in the category of non-life-threatening chest injuries. This condition results from sudden compression of the thoracic cage while the glottis is closed.4 Venous blood is driven into the capillaries; extravasation and hemorrhage may occur in soft tissues, including the brain. These patients are very frequently semicomatose, may have convulsions, and occasionally have other significant neurologic sequelae. The normal course is toward slow recovery, with disappearance of the petechial hemorrhages over the ensuing seven to 10 days.
LOCALIZED INJURIES TO THE THORAX WITH AND WITHOUT ASSOCIATED PULMONARY INJURY
This group of injuries results from localized blunt trauma to the child's chest. The underlying lung tissue may have hemorrhage and edema associated with the nonpenetrating trauma. Rarely is there significant impairment of respiratory function or serious alteration in blood gases. Complete resolution occurs without intensive hospital care.
Our general experience with major injuries in children has shown that significant thoracic injuries rarely occur alone and are usually a component of multisystem injuries. A proper sequence of evaluation of the child must be followed so that other organ systems will not be overlooked. Whatever therapy is indicated, initial attention must be directed toward maintaining an adequate airway and satisfactory ventilation and the detection and control of hemorrhage. Only in this way will optimal tissue perfusion be assured throughout resuscitation, continuing evaluation, and management. Evaluation of a young child with major blunt trauma is a diagnostic challenge that requires the greatest experience in skill and judgment. A well-organized system of resuscitation and management, including the use of monitoring techniques, is necessary in the overall care of children who have suffered major blunt trauma causing serious injuries to the chest.
1 . Bellinger. S. B. Penetrating chest injuries in children. Ann. Thorac. Surg. 14 (1972). 635.
2. Kilman, J. W., and Charneck. E. Thoracic trauma in infancy and childhood. J. Trauma 9 (1969). 863.
3. Cohn, R. Nonpenetrating wounds of the lungs and bronchi. Surg. Clin. North Am. 52 (1972). 585.
4. Haller, J. A., and Donahoo, J. S. Traumatic asphyxia in children. J. Trauma 11 (1971). 453.