Emergency Department Management of Pediatric Blunt Thoracic Injuries - Trauma EXTRA Supplement (Trauma CME)

Table of Contents

 

About This Issue

Blunt thoracic trauma in children can manifest in a variety of injuries and with a wide range of morbidity and mortality. Due to distinct anatomical and physiological traits in children, the diagnostic and management approach to these injuries can differ from those applied to adults with blunt chest injuries. In this issue, you will learn:

The most common mechanisms of blunt thoracic injury in children

Why isolated rib injuries are rare in children

When chest CT is indicated in children with blunt chest injuries

The key diagnostic studies for evaluation of suspected blunt cardiac injuries

Whether pigtail catheters or chest tubes are preferrable for the treatment of pneumothorax and hemothorax

The presenting symptoms of commotio cordis

If and when thoracotomy should be performed in the ED

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Epidemiology
7. Pathophysiology and Anatomical Considerations
8. Specific Blunt Chest Injuries
   1. Pulmonary Contusion
   2. Rib and Sternal Fractures
   3. Pneumothorax and Hemothorax
   4. Traumatic Aortic Injuries
   5. Esophageal Injuries
   6. Tracheobronchial Injuries
   7. Commotio Cordis
   8. Blunt Cardiac Injury
9. Prehospital Care
10. Emergency Department Evaluation
    1. History
    2. Physical Examination
11. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
       1. Electrocardiogram
       2. Chest Radiographs
       3. Ultrasound
       4. Chest Computed Tomography
12. Treatment
    1. Treatment of Pneumothorax and Hemothorax
    2. Volume and Blood Replacement
13. Controversies and Cutting Edge
    1. Thoracotomy
    2. Computed Tomography in Trauma
    3. Diagnosis of Cardiac Contusion
14. Disposition
15. Summary
16. Risk Management Pitfalls to Avoid in the Management of Pediatric Blunt Thoracic Trauma
17. Case Conclusions
18. Clinical Pathway for the Management of Suspected Blunt Thoracic Trauma in Pediatric Patients
19. Tables and Figures
20. References

Abstract

Pediatric chest trauma can present with a wide array of symptoms and with varying rates of morbidity and mortality. Children have unique thoracic anatomical and physiological characteristics, often necessitating diagnostic and management considerations that differ from management of blunt chest injury in adults. This review discusses diagnostic and treatment modalities for commonly encountered injuries in pediatric blunt thoracic trauma, such as pulmonary contusions, rib fractures, pneumothoraces, and hemothoraces. Rarely encountered but high-mortality injuries, including blunt cardiac injury, commotio cordis, tracheobronchial injury, and aortic injury, are also discussed.

Case Presentations

A 4-year-old boy who was involved in a high-speed MVC has arrived at your ED via EMS…

• He was an unrestrained passenger in the collision and was ejected from the vehicle.
• EMS was unable to assess breath sounds on their arrival due to the commotion on scene.
• The patient is tachycardic, with a heart rate >130 beats/min, pallor, and diaphoresis.
• His other vital signs include: blood pressure, 68/49 mm Hg; respiratory rate, 40 breaths/min; and oxygen saturation, 92% on 100% oxygen via nonrebreather.
• He is tachypneic with absent breath sounds on the right side.
• You wonder if you should proceed with immediate intervention or wait for confirmatory imaging…

A 5-year-old girl arrives via EMS after being hit by a car while riding her bicycle on the sidewalk…

• The same high-speed MVC that injured your first patient caused another car to veer off the road and hit this girl.
• EMS reports that she has a “swollen neck and chest.”
• She is mildly tachycardic, with a heart rate of 120 beats/min, and hypoxic, with oxygen saturation of 81% on room air.
• You consider the best next steps in evaluating and treating this patient...

A 16-year-old boy arrives via EMS in cardiac arrest…

• The patient was pitching in a high school baseball game and collapsed after a line-drive ball hit him in the chest.
• CPR was initiated at the scene by the paramedics.
• He is in ventricular fibrillation on arrival at the ED.
• You recognize that time is of the essence for this patient and quickly consider the options…

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Clinical Pathway for the Management of Suspected Blunt Thoracic Trauma in Pediatric Patients

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. Office of Statistics and Programming. 10 leading causes of death by age group, United States--2010. Updated March 13, 2013. Accessed October 10, 2023. (US government statistical report)

4. * Black TL, Snyder CL, Miller JP, et al. Significance of chest trauma in children. South Med J. 1996;89(5):494-496. (Retrospective study; 1356 patients) DOI: 10.1097/00007611-199605000-00009

5. * Cooper A, Barlow B, DiScala C, et al. Mortality and truncal injury: the pediatric perspective. J Pediatr Surg. 1994;29(1):33-38. (Prospective study; 25,301 patients) DOI: 10.1016/0022-3468(94)90518-5

8. * Peterson RJ, Tepas JJ 3rd, 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) DOI: 10.1016/0003-4975(94)91063-4

23. * Kessel B, Dagan J, Swaid F, et al. Rib fractures: comparison of associated injuries between pediatric and adult population. Am J Surg. 2014;208(5):831-834. (Retrospective cohort study; 6995 patients) DOI: 10.1016/j.amjsurg.2013.10.033

43. * McGwin G, Jr., Reiff DA, Moran SG, et al. Incidence and characteristics of motor vehicle collision-related blunt thoracic aortic injury according to age. J Trauma. 2002;52(5):859-865. (Retrospective study) DOI: 10.1097/00005373-200205000-00007

75. * Nagy KK, Krosner SM, Roberts RR, et al. Determining which patients require evaluation for blunt cardiac injury following blunt chest trauma. World J Surg. 2001;25(1):108-111. (Prospective study; 315 patients) DOI: 10.1007/s002680020372

106. *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) DOI: 10.1097/TA.0b013e318184ba9a

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Keywords: blunt chest trauma, blunt thoracic trauma, blunt chest injury, blunt thoracic injury, blunt cardiac injury, pulmonary contusions, rib fractures, pneumothorax, hemothorax, blunt cardiac injury, commotio cordis, tracheobronchial injury, aortic injury