Pediatric trauma is commonly encountered in the emergency department, and trauma to the head, chest, and abdomen may be a source of significant morbidity and mortality. As children have unique thoracic anatomical and physiological properties, they may present with diagnostic challenges that the emergency clinician must be aware of. This review examines the effects of blunt trauma to the pediatric chest, as well as its relevant etiologies and associated mortality. Diagnostic and treatment options for commonly encountered injuries such as pulmonary contusions, rib fractures, and pneumothoraces are examined. Additionally, this review discusses rarely encountered—yet highly lethal—chest wall injuries such as blunt cardiac injuries, commotio cordis, nonaccidental trauma, and aortic injuries.
Key words: pediatric chest trauma, thoracic trauma, chest injuries, commotio cordis, blunt cardiac injury, cardiac contusion, rib fractures, first-rib fractures, nonaccidental trauma, child abuse, aortic injury, tracheobronchial injury, chest CT
A 4-year-old boy is brought in via EMS after a high-speed motor vehicle crash where he was an unrestrained rearseat passenger. His vitals are: blood pressure, 70/39 mm Hg; heart rate, 155 beats/min; respiratory rate, 40 breaths/ min; and oxygen saturation, 94% on room air. He is pale and displays an altered mental status. He is maintaining his airway, has diminished bilateral breath sounds, and has weak peripheral pulses. He has contusions on his head and torso, with an obvious right femur deformity. After you place 2 IVs, a chest x-ray is performed, which reveals pulmonary opacification with bilateral contusions. After a 20- cc/kg saline bolus, his heart rate is 150 beats/min, but his blood pressure rises to 100/40 mm Hg. You send him for a CT scan that reveals small frontal contusions. CT scans of the neck, chest, abdomen, and pelvis are negative. As he returns from CT scan, his blood pressure drops to 68/30 mm Hg and he remains tachycardic with a heart rate of 150 beats/min.
Just as you're managing the boy who was in the motor vehicle crash, EMS notifies you that they are bringing in a 12-year-old boy who was hit in the chest with a baseball. He collapsed and stopped breathing, and bystanders started CPR and called 911. His coach had an AED and it immediately identified ventricular fibrillation. The coach shocked him once, and the boy had return of spontaneous circulation just as paramedics arrived on the scene. What is the next step for this patient?
Your next case is a 6-month-old girl brought in by her mother with 1 day of respiratory distress. The mother states that the baby has a bad cold, with some coughing. In the ED, the girl is nontoxic and appears well. She is afebrile, with a normal respiratory rate and oxygen saturation. Her lungs are clear, and there is no evidence of labored breathing. She has a small bruise on her upper back, which her mother says is from a “pinch” from her older brother. The baby passes an oral challenge and is discharged to follow up with her pediatrician the next day. A simple and straightforward case, you say to yourself…
“Serious thoracic and abdominal injuries in children often are reported as isolated instances of trauma of an unusual or dramatic type. Failure to recognize these injuries or inaccurate appraisal of damage may result in inadequate or tardy treatment.”
Dr. John L. Keeley, 19621
Trauma is the leading cause of death in toddlers, children, teenagers, and young adults.2 Worldwide, it is estimated that nearly 25% of deaths are attributed to some form of chest trauma.3 Children have unique anatomical and physiological characteristics that make them susceptible to specific injury patterns. Specifically, trauma to the pediatric thorax has several unique features that make it potentially lethal. Chest injuries account for approximately 14% of pediatric deaths from blunt trauma,4,5 and when found in association with other injuries (especially to the head, abdomen, and long bones), the mortality rate increases.6 Blunt trauma to the pediatric chest can present in a variety of ways, from the subtle and nonspecific to the dramatic and deadly. Therefore, early recognition and prompt diagnosis is paramount for the emergency clinician. This article focuses primarily on blunt chest trauma, as this is the most common form of chest injury that affects pediatric patients.
A literature search was performed in the PubMed database using the following terms (and their combinations): pediatrics, children, thoracic trauma, chest injuries, chest trauma, commotio cordis, blunt cardiac injury, cardiac contusion, myocardial contusion, rib fractures, first-rib fractures, child abuse-thorax-rib fractures, echocardiography, emergency medicine, aortic injury, tracheobronchial injury, emergency ultrasound, chest CT scan, and radiation. Additionally, the bibliographies of articles were reviewed for additional relevant publications, and over 100 studies were cited in this review. A search of the Cochrane Database of Systematic Reviews for pediatric thoracic trauma and pediatric trauma did not yield any results.
Many of the articles included here are retrospective reviews. Due to the rarity of some aspects of pediatric chest trauma (such as commotio cordis, aortic and cardiac rupture, and tracheobronchial disruption), robust prospective trials have not been performed on these topics. For this review, we primarily examined articles focusing on blunt trauma in the pediatric patient, although some studies did include penetrating trauma as well as adult patients. Prospective studies are also included when possible, including Chest NEXUS, a prospective study of nearly 10,000 patients, although this is a study of older adolescents and adults, it has some relevance to the overall topic of blunt chest trauma.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.
Denis R. Pauzé, MD, FAAP, FACEP, FAAEM; Daniel K. Pauzé, MD, FACEP
November 1, 2013