Emergency Management Of Blunt Chest Trauma In Children: An Evidence-Based Approach (Trauma CME)
0
TOC Will Appear Here

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

1,941 views
Below is a free preview. Log in or subscribe for full access. Or, get a free sample article ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion:
Please provide a valid email address.
Table of Contents
 
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

 Table 1. Physical Examination Findings To Predict Chest Injuries In The Pediatric Patient

Table 2. Abdominal Computed Tomography And Chest X-Ray To Identify Significant Blunt Chest Trauma

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.

  1. Keeley JL. Trunk trauma in children. Postgrad Med. 1962;32:239-245.
  2. Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 10 leading causes of death by age group, United States--2010. Available at: http://www.cdc.gov/injury/ wisqars/pdf/10LCID_All_Deaths_By_Age_Group_2010- a.pdf. Accessed March 13, 2013. (United States government statistical report)
  3. Lema MK, Chalya PL, Mabula JB, et al. Pattern and outcome of chest injuries at Bugando Medical Centre in Northwestern Tanzania. J Cardiothorac Surg. 2011;18(6):6-7. (Retrospective review; 150 adult and pediatric patients)
  4. * Holmes JF, Sokolove PE, Brant WE, et al. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med. 2002;39(5):492-499. (Prospective study; 986 patients)
  5. Cooper A, Barlow B, DiScalta et al. Mortality and truncal injury: the pediatric perspective. J Pediatr Surg. 1994;29(1):33- 38. (Retrospective review; 25,301 patients)
  6. Bliss D, Silen M. Pediatric thoracic trauma. Crit Care Med. 2002;30(11):S409-S415. (Review article)
  7. Lis EF, Frauenberger GS. Multiple fractures associated with subdural hematoma in infancy. Pediatrics. 1950;6(6):890-892. (Case report)
  8. Bickford BJ. Chest injuries in childhood and adolescence. Thorax. 1962;17:240-243. (Retrospective review)
  9. Hanafi M, Al-Sarraf N, Sharaf H, et al. Pattern and presentation of blunt chest trauma among different age groups. Asian Cardiovasc Thorac Ann. 2011;19(1):48-51. (Retrospective review; 486 pediatric, adult, and elderly patients)
  10. Ismail MF, Ibrahim al-Rafaie R. Chest trauma in children, single center experience. Arch Bronchopneumol. 2012;48(10):363- 366. (Retrospective review; 472 pediatric patients)
  11. Peterson RJ, Tepas JJ III, Edwards FH, et al. Pediatric and adult thoracic trauma: age-related impact on presentation and outcome. Ann Thorac Surg. 1994;58(1):14-18. (Retrospective review; 2415 patients)
  12. Black, TL, Snyder CL, Miller JP, et al. Significance of chest trauma in children. South Med J. 1996;89(5):494-496. (Retrospective review; 82 patients)
  13. Peclet MH, Newman KD, Eichelberger MR, et al. Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg. 1990;25(9):961-966. (Prospective study; 2086 patients)
  14. Sartorelli KH, Vane DW. The diagnosis and management of children with blunt injury to the chest. Semi Ped Surg. 2004;13(2):98-105. (Review article)
  15. Nakayama DK, Ramenofsky ML, Rowe MI. Chest injuries in childhood. Ann Surgery. 1989;210(6):770-775. (Retrospective review; 105 patients)
  16. Ceran S, Suram GS, Aribas OK, et al. Chest trauma in children. Eur J Cardiothoracic Surg. 2002;21(1):57-59. (Retrospective study; 225 patients)
  17. Bulloch B, Schubert CJ, Brophy PD, et al. Cause and clinical characteristics of rib fractures in infants. Pediatrics. 2000;105(4):E48. (Retrospective review; 39 patients)
  18. Balci AE, Kazez A, Eren S, et al. Blunt thoracic trauma in children: review of 137 cases. Eur J Cardiothorac Surg. 2004;26(2):387-392. (Retrospective review; 137 patients)
  19. Demetriades D, Murray J, Martin M, et al. Pedestrians injured by automobiles: relationship of age to injury type and severity. J Am Coll Surg. 2004;199(3):382-387. (Trauma registry study; 5838 patients)
  20. Smyth BT. Chest trauma in children. J Pediatr Surg. 1979;14(1):41-47. (Retrospective review; 94 patients)
  21. Inan M, Ayvaz S, Sut N, et al. Blunt chest trauma in childhood. ANZ J Surg. 2007;77(8):682-685. (Retrospective review; 44 patients)
  22. Kissoon N, Dreyer J, Walia M. Pediatric trauma: differences in pathophysiology, injury patterns and treatment compared with adult trauma. CMAJ. 1990;142(1):27-34. (Review)
  23. Cooper A, Barlow B, DiScala C, et al. Mortality and truncal injury: the pediatric perspective. J Pediatr Surg. 1994;29(1):33- 38. (Retrospective review; 25,301 patients)
  24. Velmahos GC, Karaiskakis M, Salim AS, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003;54(1):45-50. (Prospective observational study; 333 patients)
  25. Rajan GP, Zellweger R. Cardiac troponin I as a predictor of arrhythmia and ventricular dysfunction in trauma patients with myocardial contusion. J Trauma. 2004;57(4):801-808. (Retrospective comparative review; 187 patients)
  26. Hirsch R. Landt Y, Porter S, et al. Cardiac troponin I in pediatrics: normal values and potential use in the assessment of cardiac injury. J Pediatr. 1997;130(6):872-827. (Retrospective comparative study; 216 patients)
  27. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST). J Trauma. 2004;57(2):288-295. (Prospective study; 225 patients)
  28. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17(1):11-17. (Combination of 4 prospective observational studies; 606 patients)
  29. Hyacinthe AC, Broux C, Francony G, et al. Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma. Chest. 2012;141(5):1177-1183. (Prospective observational cohort study; 119 adult patients)
  30. Renton J, Kincaid S, Ehrlich PF. Should CT helical scanning of the thoracic cavity replace the conventional chest x-ray as a primary assessment tool in pediatric trauma? An efficacy and cost analysis. J Pediatr Surg. 2003;38(5):793-797. (Retrospective review; 45 patients)
  31. Blostein PA, Hodgman CD. Computed tomography of the chest in blunt thoracic trauma: results of a prospective study. J Trauma. 1997;43(1):13-18. (Prospective study; 40 patients)
  32. Holscher CM, Faulk LW, Moore EE, et al. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res. 2013;184(1):352-357. (Evaluation of trauma team evaluations over 6 years; 174 patients)
  33. Barrios C, Pham J, Malinoski D, et al. Ability of a chest x-ray and an abdominal computed tomography to identify traumatic thoracic injury. Am J Surg. 2010;200(6):741-744. (Retrospective study; 374 trauma patients)
  34. Pinette W, Barrios C, Pham J, et al. A comparison of thoracic CT and abdominal CT for the identification of thoracic blunt trauma. Am J Surg. 2012;204(6):927-931. (Prospective observational study; 444 patients)
  35. Lowe LH, Bulas DI, Eichelberger MD, et al. Traumatic aortic injuries in children: radiologic evaluation. Am J Roentgenol. 1998;170(1):39-42. (Retrospective review; 7 patients)
  36. Markel TA, Kumar R, Koontz NA, et al. The utility of computed tomography as a screening tool for the evaluation of pediatric blunt chest trauma. J Trauma. 2009;67(1):23-28. (Retrospective review; 333 patients)
  37. Guerror-López F, Vázquesz-Mata G, Alcázar-Romero PP, et al. Evaluation of the utility of computed tomography in the initial assessment of the critical care patient with chest trauma. Crit Care Med. 2000:28(5):1370-1375 (Prospective observational study; 375 patients)
  38. Kea B, Gamarallage R, Vairamuthu H, et al. What is the clinical significance of chest computed tomography when the chest x-ray result is normal in patients with blunt trauma? Am J Emerg Med. 2013; 31(8):1268-1273. (Retrospective review; 791 patients)
  39. Rodriguez RM, Anglin D, Langdorf MI, et al. NEXUS Chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg. 2013;148(10):940-946. (Prospective observational study; 9905 patients)
  40. Plummer D, Brunette D, Asinger R, et al. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann Emerg Med. 1992;21(6):709-712. (Retrospective chart review; 49 patients)
  41. Pearson GD, Karr SS, Trachiotis GD, et al. A retrospective review of the role of transesophageal echocardiography in aortic and cardiac trauma in a level 1 pediatric trauma center. J Am Soc Echocardiogr. 1997;10(9):946- 955. (Retrospective chart review; 10 patients)
  42. Balci AE, Eren N, Eren S, et al. Surgical treatment of posttraumatic tracheobronchial injuries: 14-year experience. Eur J Cardiothoracic Surg. 2002;22(6):984-989. (Retrospective review; 32 patients)
  43. Davies D, Hopkins JS. Patterns in traumatic rupture of the bronchus. Injury. 1973;4(3):261-264. (Review)
  44. Mordehai J, Kurzbart E, Kapuller V, et al. Tracheal rupture after blunt chest trauma in a child. J Pediatr Surg. 1997;32(1):104-105. (Case report and literature review)
  45. Gaebler C, Mueller M, et al. Tracheobronchial ruptures in children. Am J Emerg Med. 1996;14(3):279-284. (Case series; 4 patients)
  46. Baumgartner F, Sheppard B, de Virgilio C, et al. Tracheal and main bronchial disruptions after blunt chest trauma: presentation and management. Ann Thorac Surg. 1990;50(4):569-574. (Retrospective review; 9 patients)
  47. Nakayama DK, Rowe MI. Intrathoracic tracheobronchial injuries in childhood. Int Anesthesiol Clin. 1988;26(1):42-49. (Review)
  48. Bender TM, Oh KS, Medina JL, et al. Pediatric chest trauma. J Thorac Imag. 1987;2(3):60-67. (Review)
  49. Harvey-Smith W, Bush W, Northrop C. Traumatic bronchial rupture. Am J Roentgenol. 1980;134(6):1189-1193. (Case series; 3 patients)
  50. Poli-Merol ML, Beloudah M, Parvy F, et al. Tracheobronchial injury by blunt trauma in children: is emergency tracheobronchospy always necessary? Eur J Pediatr Surg. 2003;13(6):398-402. (Retrospective review; 3 patients)
  51. Allen GS, Cox CS Jr. Pulmonary contusion in children: diagnosis and management. South Med J. 1998;91(12):1099-1106. (Systematic review)
  52. Cohn SM. Pulmonary contusion: review of the clinical entity. J Trauma. 1997;42(5):973-979. (Review article)
  53. Kwon A, Sorrells DL, Kurkchubasche AG, et al. Isolated computed tomography diagnosis of pulmonary contusion does not correlate with increased morbidity. J Pediatr Surg. 2006;41(1):78-82. (Retrospective review; 82 patients)
  54. Wagner R, Slivko B, Jamieson PM, et al. Effect of lung contusion on pulmonary hemodynamics. Ann Thorac Surg. 1991;52(1):51-58. (Case series; 25 patients)
  55. Blostein P, Hodgman C. Computed tomography of the chest in blunt thoracic trauma: results of a prospective study. J Trauma. 1997;43(1):13-18 (Prospective series; 40 patients)
  56. Soldati G, Testa A, Silva FR, et al. Chest ultrasonography in lung contusion. Chest. 2006;130(2):533-538. (Retrospective and prospective combined study; 109 patients)
  57. Stone MB, Secko MA. Bedside ultrasound diagnosis of pulmonary contusion. Pediatr Emerg Care. 2009;25(12):854-855. (Case report and discussion)
  58. Grisoni ER, Volsko TA. Thoracic injuries in children. Respir Care Clin N Am. 2001;7(1):25-38. (Review)
  59. Kulvatunyou N, Joseph B, Friese RS, et al. 14 french pigtail catheters placed by surgeons to drain blood on trauma patients: is 14-Fr too small? J Trauma Acute Care Surg. 2012;73(6):1423-1427. (Prospective data of 36 pigtail catheters compared to retrospective data of 191 chest tubes)
  60. Eddy AC, Rusch VW, Fligner CL, et al. The epidemiology of traumatic rupture of the thoracic aorta in children: a 13-year review. J Trauma. 1990;30(8):898-991. (Retrospective review)
  61. Heckman SR, Trooskin SZ, Burd RS. Risk factors for blunt thoracic aortic injury in children. J Pediatr Surg. 2005;40(1):98- 102. (Retrospective review; 26,940 patients)
  62. Pabon-Ramos WM, Williams DM, Strouse PJ. Radiologic evaluation of blunt thoracic aortic injury in pediatric patients. AJR Am J Roentgenol. 2010;194(5):1197-1203. (Retrospective review; 17 patients)
  63. Anderson SA, Day M, et al. Traumatic aortic injuries in the pediatric population. J Pediatr Surg. 2008;43(6):1077-1081. (Retrospective review; 11 patients)
  64. Parmley LF, Mattingly TW, Manion WC, et al. Nonpenetrating traumatic injury of the aorta. Circulation. 1958;17(6):1086- 1101. (Review)
  65. Trachiotis GD, Sell JE, Pearson GD, et al. Traumatic thoracic aortic rupture in the pediatric patient. Ann Thorac Surg. 1996;62(3):724-731. (Retrospective review; 6 patients)
  66. Cox CS, Black CT, Duke JH, et al. Operative treatment of truncal vascular injuries in children and adolescents. J Pediatr Surg. 1998;33(3):462-467. (Retrospective review; 37 patients)
  67. Schmidt CA Jacobson JG. Thoracic aortic injury: a ten-year experience. Arch Surg. 1984; 119(11):1244-1246. (Retrospective review; 41 patients)
  68. Tiao GM, Griffith PM, Szmuszkowvicz JR, et al. Cardiac and great vessel injuries in children after blunt trauma: an institutional review. J Pediatr Surg. 2000;35(11):1656-1660. (Retrospective review; 2744 patients)
  69. Greene R. Lung alterations in thoracic trauma. J Thorac Imaging. 1987;2(3):1-11. (Review)
  70. White CS, Mirvis SE. Pictorial review: imaging of traumatic aortic injury. Clin Radiol. 1995;50(5):281-287. (Retrospective pictorial and review; 120 patients)
  71. Mirvis SE, Bidwell JK, et al. Value of chest radiography in excluding aortic rupture. Radiology. 1987;163(2):487-493. (Retrospective review; 205 patients)
  72. Dyer DS, Moore EE et al. Can chest CT be used to exclude aortic injury? Radiology. 1999;213(1):195-202. (Prospective observational study; 1009 patients)
  73. U.S. Department of Health & Human Services. Children’s Bureau. Child maltreatment 2011. Available at: http://www. acf.hhs.gov/sites/default/files/cb/cm11.pdf. Accessed March 13, 2013. (United States government statistical report)
  74. * Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621-626. (Retrospective review; 173 cases)
  75. * Bulloch B, Schubert JC, Brophy PD, et al. Cause and clinical characteristics of rib fractures in infants. Pediatrics. 2000;105(4):E48. (Retrospective chart review; 39 patients)
  76. Cadzow SP, Armstrong KL. Rib fractures in infants: red alert! The clinical features, investigations, and child protection outcomes. J Paediatr Child Health. 2000;36(4):322-326. (Retrospective review; 18 patients)
  77. Barsness KA, Cha ES, Bensard DD, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma. 2003;54(6):1107-1110. (Retrospective chart review; 62 patients)
  78. Melville JD, Lukefahr JL, Clarke EA. First-rib fractures in abused infants: a report of three cases. Clin Pediatr. 51(5):426- 430. (Case reports; 3 patients)
  79. Gupta A, Jamshidid M, Rubin JR. Traumatic first rib fracture: is angiography necessary? A review of 730 cases. Cardiovasc Surg. 1997;5(1):48-53. (Review)
  80. Hamilton NA, Bucher BT, Keller MS. The significance of first-rib fractures in children. J Ped Surg. 2011;46(1):169-172. (Retrospective chart review; 33 patients)
  81. Scorpio RJ, Wesson DE, Smith CR, et al. Blunt cardiac injuries in children: a postmortem study. J Trauma. 1996;41(2):306-309. (Autopsy study)
  82. Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin. 2004;20(1):57-70. (Review)
  83. Dowd MD, Krug S. Pediatric blunt cardiac injury: epidemiology, clinical features and diagnosis. Pediatric Emergency Medicine Collaborative Research Committee: Working Group on Blunt Cardiac Injury. J Trauma. 1996;40 (1):61-67. (Retrospective review; 184 patients)
  84. Turk EE, Tsang YW, Champaneri A, et al. Cardiac injuries in car occupants in fatal motor vehicle collisions--an autopsybased study. J Forensic Leg Med. 2010;17(6):339-343. (Autopsy review; 80 cardiac injuries in 380 patients)
  85. * Kaptein YE, Talving P, Konstantinidis A, et al. Epidemiology of pediatric cardiac injuries: a National Trauma Data Bank Analysis. J Ped Surg. 2011;46(8):1564-1571. (Database analysis; 626 patients with cardiac injuries)
  86. Ildstad ST, Tollerud DJ, Weiss RG, et al. Cardiac contusion in pediatric patients with blunt thoracic trauma. J Pediatr Surg. 1990;25(3):287-289. (Prospective; 7 patients)
  87. Tellez DW, Hardin WD, Takahashi M, et al. Blunt cardiac injury in children. J Ped Surg. 1987;22(12):1123-1128. (Review; 39 patients)
  88. Roland J et al. Right atrial rupture from blunt thoracic trauma in a 4-year old child. Ped Emerg Care. 2009;25(3):188- 189. (Case report)
  89. Scolan V, Stahl C, Eysseric H, et al. Rupture of the left ventricle due to blunt trauma--a pediatric case study and literature review. J Forensic Leg Med. 2011;18(5):217-220. (Case study)
  90. Maron BJ, Estes NA. Commotio cordis. New Engl J Med. 2010;362(10):917-927. (Review article)
  91. Maron BJ, Gohman TE, Kyle SB, et al. Clinical profile and spectrum of commotio cordis. Commotio cordis. JAMA. 2002;287(9):1142-1146. (Review; 128 patients from the Commotio Cordis Registry)
  92. Zangwill SD, Strasburger JF. Commotio cordis. Pediatr Clin North Am. 2004;51(5):1347-1354. (Review)
  93. Baker AM, Craig BR, Lonergan GJ et al. Homicidal commotio cordis: the final blow in a battered infant. Child Abuse Negl. 2003;27(1):125-130. (Case report)
  94. Denton JS, Kalelkar MB. Homicidal commotion cordis in two children. J Forensic Sci. 2000;45(3):734-745. (Case report)
  95. Lucena JS, Rico A, Salguero M, et al. Commotio cordis as a result of a fight: report of a case considered to be imprudent homicide. Forensic Sci Int. 2008;177(1):e1-e4. (Case report)
  96. Yeh CC, Hsieh CH, Wang YC, et al. Commotio cordis as a rare cause of traumatic cardiac arrest in motorbike crashes: report of a case. Surg Today. 2010;40(4):369-372. (Case report)
  97. Miyazaki T, Ihama Y, Fuke C. An autopsy case of commotio cordis from a motor scooter accident. Leg Med (Tokyo). 2008;10(5):264-267. (Case report)
  98. Kutsukata N, Mashiko K, Matsumoto H, et al. A case of commotio cordis caused by steering wheel injury. J Nippon Med Sch. 2010;77(4):218-220. (Case report)
  99. Maron BJ, Haas TS, Ahluwalia A, et al. Increasing survival rate from commotion cordis. Heart Rhythm. 2013;10(2):219- 223. (Retrospective review)
  100. Dull KE, Fleisher GR. Pigtail catheters versus large-bore chest tubes for pneumothoraces in children treated in the emergency department. Pediatr Emerg Care. 2002;18(4):265- 267. (Retrospective review; 27 patients)
  101. Roberts JS, Bratton SL, Brogan TV. Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients. Chest. 1998;114(4):1116-1121. (Retrospective chart review; 91 children requiring 133 chest catheters)
  102. Kuo HC, Lin YJ, Huang CF, et al. Small-bore pigtail catheters for the treatment of primary spontaneous pneumothorax in young adolescents. Emerg Med J. 2013;30(3):e17. (Retrospective study; 41 patients)
  103. Frush DP, Donnelly LF, Rosen NSA. Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics. 2003;112(4):951-957. (Review)
  104. Brody AS, Frush DP, Huda W, et al. Radiation risk to children from computed tomography. Pediatrics. 2007;120(3):677- 682. (Review)
  105. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012;380(9840):499-505. (Retrospective cohort study; 355,191 patients)
  106. GE Healthcare Press release. GE Healthcare Unveils Ultra- Low Dose CT Technology with Profound Image Clarity. September 20, 2011. (Corporate press release)
  107. GE Healthcare Brochure: Introducing Veo on Discovery CT750 HD. (Manufacturer brochure)
  108. Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury. 2012;43(1):8-17. (Systematic review)
  109. Torelli L, Zoccali G, Casarin M, et al; Comparative evaluation of the haemodynamic effects of continuous negative external pressure (CNEP) and positive end-expiratory pressure (PEEP) in mechanically ventilated trauma patients. Intensive Care Med. 1995;21(1):67-70. (15 patients)
  110. Shah PS, Ohlsson A, Shah JP. Continuous negative extrathoracic pressure or continuous airway pressure for children with acute respiratory failure and shortage of oxygen. Cochran Database Syst Rev. 2008 Jan 23; (1):CD003699. (Cochrane systematic review)
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Publication Information
Authors

Denis R. Pauzé, MD, FAAP, FACEP, FAAEM; Daniel K. Pauzé, MD, FACEP

Publication Date

November 1, 2013

Get Permission

Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.