SAN DIEGO – Many thoracic injuries sustained by children and adolescents can be diagnosed with clinical assessment and chest x-ray, and many heal without surgical intervention, according to Dr. Timothy Fairbanks.
"When the pager goes off and says ‘3-year-old involved in a accident,’ that kid may be going home with a physical exam, stickers, and a high five; or he may require a life-saving procedure" in the emergency department. Dr. Fairbanks, of the division of pediatric surgery at Rady Children’s Hospital of San Diego, said at the University of California, San Diego, Critical Care Summer Session. "There’s complete variability in what we see and how serious the injuries can be."
Dr. Timothy Fairbanks
According to data from the National Pediatric Trauma Registry, 86% of injuries are blunt and 14% are penetrating. Chest injuries "are the second leading cause of death to central nervous system injuries," Dr. Fairbanks said. "Mortality rates for blunt and penetrating injuries are similar. In blunt traumas, most kids don’t die from their blunt thoracic injury, but from a CNS injury that they acquired at the same time. Most of the kids who die from penetrating injuries die in the field before reaching the hospital."
Thoracic injuries occur in about 25% of patients who present to a Level I trauma center. While thoracic injuries are less common than abdominal and extremity injuries are, "they are of potentially higher risk and more lethal," he said. "Most can be treated successfully. Male to female injury rate is 2:1 to 3:1 in favor of males having more traumas."
He classifies thoracic trauma injuries by anatomy (rib, pulmonary, bronchial), blunt vs. penetrating, and threat to life (immediate or potentially life threatening). Motor vehicles are the most common mechanism of thoracic injury, and children have an increased risk in all traumas of auto vs. pedestrian, compared with adults. "When children become teenagers, their mechanisms of injuries approach those of the data for adults," Dr. Fairbanks explained. "We see more penetrating knife and gunshot wounds to the chest, although they are rare in our younger patient population. Tracheobronchial lacerations are more common in children, compared with adults. Aortic disruptions are less likely in children."
Common thoracic injuries that he and his associates see at Rady Children’s Hospital are lung contusion, pneumothorax, hemothorax, and fractures to the ribs, sternum, or scapula. Less common "but perhaps more dangerous injuries" are those to the heart, aorta, trachea, bronchi, and diaphragm. "The most common immediately life-threatening thoracic injuries in children are airway obstruction, pneumothorax, hemothorax, and cardiac tamponade," he said. "A large percentage of thoracic injuries have stable vital signs at presentation. Rib fractures are less common in children and are a marker for a significant mechanism of injury or force. Mediastinal structures are more mobile, making tension pneumothorax a bigger problem."
Diagnosis and treatment of thoracic injuries proceeds simultaneously, with an initial goal to rule out life-threatening injuries, which should be identified and treated during the initial resuscitation phase. This includes making sure the airway is clear and secure and providing supplemental oxygen. "If endotracheal intubation is needed, check the position," he advised. "You want to see bilateral chest rise and CO2 waveform on your monitor. It’s very common for a child to have a right mainstem intubation and no breath sounds on the left side." He also makes it a point to assess their ventilation and treat their pneumothorax. "Don’t wait for the chest x-ray if you have a good clinical suspicion," he said.
A chest x-ray can often guide your management decisions in cases of thoracic trauma, while a FAST scan – specifically an ultrasound – is good for seeing a cardiac tamponade.
Sometimes thoracic injuries require an immediate thoracotomy in the emergency department, but its indications "are controversial," Dr. Fairbanks said. "It’s a potentially life-threatening maneuver, especially with penetrating cardiac injuries." The indications for emergency department thoracotomy are post-traumatic arrest or near arrest in all cases of penetrating thoracic injuries; in blunt trauma with loss of vital signs in the ED; or in blunt trauma with loss of vital signs in route to the ED.
"One of the things we struggle with in pediatric trauma is the timing at which they lost the vital signs in the field," he said. "After 20 minutes the chance of survival is almost nil. However, the family is going to want to know that you did everything possible to save their 3- or 4-year-old child."
If the patient is stable, complete the physical exam. "You’re looking for tachypnea, tenderness to the chest wall and abrasions, or signs of thoracic trauma that require further investigation," he said. Important signs include cyanosis, dyspnea, tracheal deviation, hoarseness, jugular engagement, and subcutaneous emphysema.