Emergency Management Of Blunt Chest Trauma In Children: An Evidence-Based Approach (Trauma CME)

Table of Contents

 

1. Abstract
2. Case Presentation
3. Introduction
4. Critical Appraisal Of The Literature
5. Etiology And Epidemiology
   1. Etiology
      1. Types Of Chest Injuries
      2. Mortality
   2. Anatomy And Physiology
6. Prehospital Care
7. Emergency Department Evaluation
   1. History
   2. Physical Examination
   3. Emergent Stabilization
   4. A Clinical Decision Rule For Identifying Chest Trauma
8. Diagnostic Studies
   1. Laboratory Studies
   2. Electrocardiogram
   3. Imaging Studies
      1. Chest X-Ray
      2. Ultrasound
      3. Chest Computed Tomography
      4. Echocardiography
9. Differential Diagnosis
10. Specific Thoracic Injuries
    1. Tracheobronchial Injury
    2. Pulmonary Contusions And Lacerations
    3. Pneumothorax And Hemothorax
    4. Aortic Injury
       1. Radiographic Findings In Aortic Injuries
    5. Nonaccidental Injury
    6. First-Rib Fracture
    7. Blunt Cardiac Injury
       1. Diagnosing Blunt Cardiac Injury
       2. Commotio Cordis
11. Treatment
12. Controversies And Cutting Edge
    1. Chest Computed Tomography Scans And Radiation Exposure
    2. Low-Radiation Computed Tomography Scans
    3. Negative Pressure Ventilation
    4. Experimental Treatments
13. Disposition
14. Summary
15. Risk Management Pitfalls For Chest Trauma In Children
16. Case Conclusion
17. Clinical Pathway For Management Of The Pediatric Patient With Suspected Blunt Chest Trauma
18. Clinical Pathway For Management Of The Pediatric Patient With Blunt Chest Trauma And Abnormal Chest X-Ray
19. Tables and Figures
    1. Table 1. Physical Examination Findings To Predict Chest Injuries In The Pediatric Patient
    2. Table 2. Abdominal Computed Tomography And Chest X-Ray To Identify Significant Blunt Chest Trauma
    3. Figure 1. Prevalence Of Thoracic Injuries
    4. Figure 2. Multiple Rib Fractures In An Infant With Nonaccidental Trauma
    5. Figure 3. Cardiac Tamponade In A 4-Year-Old Girl
    6. Figure 4. Electrocardiographic Representation Of Commotio Cordis Risk Window
20. References

Abstract

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

Case Presentation

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…

Introduction

“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.

Critical Appraisal Of The Literature

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.

Risk Management Pitfalls For Chest Trauma In Children

1. “The infant presented with shortness of breath. There was no fever, the oxygen saturation was normal, and the lungs were clear. I thought it was respiratory syncytial virus. I didn’t think it could be from abusive chest trauma.” Infants with abusive head trauma and/or abusive chest trauma can present with nonspecific signs and symptoms, including respiratory complaints. These patients may present similarly to infants with bronchiolitis. Emergency clinicians should look for the presence of upper respiratory symptoms, runny nose, fevers, etc, that may indicate an upper respiratory infection or bronchiolitis. Absence of these symptoms should generate a high index of suspicion to evaluate for potential nonaccidental trauma.
2. “The 7-year-old presented with confusion and a femur fracture. His CT scan showed a splenic laceration. I didn’t think his persistent hypotension was caused by a cardiac tamponade.” Blunt cardiac injury is usually seen in a patient with multisystem injuries. Emergency clinicians may be distracted when seeing additional injuries (such as intra-abdominal pathology or extremity fractures). It is important to consider blunt cardiac injury when assessing the child with multisystem injury.
3. “The 4-year-old boy came in after a high-speed car accident. He was not belted and was thrown into the windshield. His chest x-ray revealed multiple rib fractures and a pneumothorax. He was admitted to the pediatric intensive care unit, where they subsequently found a traumatic aortic dissection. I can’t believe I forgot to look at his mediastinum on the chest x-ray! It was definitely widened. I didn’t think children could have this injury.” Emergency clinicians should carefully examine the chest x-ray for abnormalities such as widened mediastinum or abnormal apical knob. Although aortic injuries are uncommon in the pediatric patient, they do occur.
4. “The 8-year-old was riding her bike when she was struck by a car. Her initial heart rate was 140 beats/min with a blood pressure of 70/30 mm Hg. She presented with a GCS score of 10 and was immediately intubated. Chest x-ray revealed rib fractures. Her FAST exam was negative, and CT of chest and abdomen was negative for acute injury. She remained tachycardic and intermittently hypotensive. What injury am I missing with a negative pan scan?” This young girl was later diagnosed with a cardiac contusion, the most common form of blunt cardiac injury. Clues to her diagnosis were tachycardia, rhythm abnormalities, and hypotension. An ECG and troponin may have helped with the diagnosis.
5. “The 5-year-old girl presented after a large TV fell on her chest. She arrived tachycardic with a blood pressure of 100/65 mm Hg. Her initial oxygen saturation was 99% and her chest x-ray revealed only 2 rib fractures. Three hours later, she developed respiratory distress and became hypoxic, with an oxygen saturation of 82%. I had to intubate her. Repeat chest x-rays revealed a large pulmonary contusion. How did I miss it?” Findings of pulmonary contusion may be delayed for several hours in the pediatric patient. Respiratory distress and hypoxia may develop after an initial chest x-ray that is normal. The emergency clinician should be aware of delayed clinical findings from a developing pulmonary contusion. Initial findings to suggest a developing pulmonary contusion includes relative hypoxia, with saturations in the 93% to 95% range.
6. “We came to the scene of a 7-year-old with head, chest, and abdominal trauma. She was breathing OK with a saturation of 97%. Looking back at the record, I can’t believe we spent 44 minutes on the scene. We should have transported faster.” Prehospital delay of transport should be avoided as much as possible, especially if the delay is from repeated intravenous or intubation attempts. Emphasis should be placed on oxygenation, ventilation, treatment of tension pneumothorax, intravenous/intraosseous access, and spinal motion restriction. Specific attention to oxygenation/ventilation is the first priority, and this can usually be accomplished with manual airway maneuvers; intubation is rarely required for pediatric patients.
7. “The 2-year-old boy presented with a high respiratory rate, hypotension, head injury with altered mental status, and a femur fracture. I was distracted by his other injuries. I can’t believe I missed the first-rib fracture, cardiac contusion, and small aortic tear. I was distracted by his other injuries.” A high index of suspicion is needed to diagnose chest trauma. External injuries may not be immediately evident, and other organ systems may distract the emergency clinician. Holmes et al found 6 clinical findings that helped to predict chest injuries. These include: (1) abnormal chest auscultation, (2) low systolic blood pressure, (3) GCS score < 15, (4) abnormal thoracic examination, (5) elevated respiratory rate, and (6) femur fracture.⁴
8. “The 8-year-old presented after a motor vehicle crash. His chest x-ray was normal. Everyone wanted to pan scan him to rule out any occult injuries, so we did. We found a small pulmonary contusion and 1 rib fracture. I don’t think the pan scan added anything to our clinical management, and this patient received unnecessary radiation exposure.” Barrios and Holscher identify a high-risk mechanism (deceleration injury, crush torso injury) or an abnormal chest x-ray (wide mediastinum) as potential indications for chest CT scan, looking for an aortic disaster or a potential tracheobronchial disruption. With a normal chest x-ray, this patient did not meet any of the criteria for a chest CT scan.32,33
9. “The 9-year-old boy presented after a fall from a height of 20 feet. He arrived with a blood pressure of 70/30 mm Hg and a heart rate of 140 beats/min. He was awake and alert. We did a CT scan of his head, neck, chest, abdomen, and pelvis, all of which were negative. He remained tachycardic and hypotensive. I can’t believe I missed a severe myocardial contusion. I didn’t even think of the heart.” This is a perfect example of a patient with a negative pan scan who still has a severe undiagnosed injury. Patients with significant cardiac injury will commonly present with hypotension or arrhythmia. They may be nonresponsive to fluid resuscitation. Dowd’s review of patients with blunt cardiac injury found that patients with significant cardiac injuries were in shock or had ECG abnormalities upon initial presentation.83 Patients with hemodynamic instability should also be evaluated for a blunt cardiac injury such as myocardial contusion. Serial ECGs, serial troponin measurements, and echocardiography are available diagnostic tools. Echocardiography evaluates for tamponade, wall or valve rupture, wall motion function, and ejection fraction.
10. “A 13-year-old presented after falling off his bicycle. He complained of chest pain. He had normal vital signs and significant abrasions to his head and trunk. Chest x-ray revealed a large pneumothorax, not under tension. We placed a 32-French chest tube in him. It was painful. I completely forgot I could have placed a small pigtail catheter, which would have saved him a lot of pain and discomfort.” Thoracostomy by pigtail (as opposed to largebore stiff chest tube) is an acceptable alternative in pneumothoraces. Dull and Fleischer found that children undergoing pigtail catheterization for pneumothorax under Seldinger technique had a similar length of stay and required less opioid use compared to children who had largebore chest tube.¹⁰⁰

Tables and Figures

References

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.

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