Blunt Thoracic Guidelines

 

Pediatric Blunt Thoracic Trauma

 

Background                                        

•           Blunt thoracic injuries in children are relatively uncommon but result in a disproportionate percentage of morbidity and mortality compared with other traumatic injuries
•          The most common blunt thoracic injuries in children are rib fractures, pneumothoraces, hemothoraces and pulmonary contusions. 
•          Less common thoracic injuries in children include cardiac injury, thoracic aorta injury, tracheobronchial injury, esophageal injury and diaphragmatic rupture.

Exam

•           Ensure patent airway.
•           Assess for tachypnea and adequate oxygenation.
•           Evaluate bilateral hemithoraces for symmetric motion and auscultation
•           Evaluate chest wall for bruising, crepitus, flail segments, tenderness to palpation
•           Evaluate for equal pulses in extremities

Radiographic Assessment

•        Plain CXR should be utilized to screen for significant thoracic injuries.  If normal, no additional imaging is typically indicated.
•        eFAST is a useful adjunct to evaluate for pericardial fluid, pneumothoraces and hemothoraces
•       CT scan of the chest is rarely required in blunt pediatric thoracic trauma
•       Indications for CT scan may include
•       Abnormal CXR
•       Pulse differential/unequal blood pressures in extremities
•       Traumatic chest wall deformities
•       If cross sectional imaging is required, obtain CTA of chest
•      ECHO may be required if blunt cardiac injury (BCI) is suspected
•     Clinical signs consistent with BCI include chest pain, shortness of breath, muffled heart sounds, dysrhythmias, low cardiac output and hypotension in association with chest wall trauma.4
•       EKG and enzyme analysis (troponin) are useful also diagnostic tools for BCI.

Management

Pneumothorax:

•          Asymptomatic small pneumothoraces can be safely observed. 
•          Symptomatic or large pneumothoraces require tube thoracostomy.

Hemothorax: 

•       Asymptomatic small hemothoraces can be safely observed. 
•       Moderate-large or symptomatic hemothoraces require tube thoracostomy
•      Thoracotomy should be considered
•  With hemodynamic instability attributed to bleeding in the chest
•  If initial thoracostomy tube output is >/= 15ml/kg
•  If thoracostomy output is >2-3ml/kg/hr over the following 6 hours after chest tube placement

Pulmonary Contusion

•          Note that increased flexibility of the chest wall makes pulmonary contusions without concomitant rib fractures more common in children than adults.
•          Treatment is typically supportive care
•      Non-invasive or invasive respiratory support
•       Judicious fluid management
•       Pain control if rib or sternal fractures present
•       Aggressive pulmonary toilet
•           Severe unilateral pulmonary contusions may benefit from use of a double lumen endobronchial tube connected to 2 ventilators (synchronized independent lung ventilation)

Rib and Sternal Fractures

•           Rib fractures are an important marker of severe injury in children
•           Note that there is a high incidence of rib fractures in children with non-accidental trauma
•           Sternal fractures have a high association with blunt cardiac injury
•           The mainstay of treatment for rib and sternal fractures includes adequate pain control to promote effective oxygenation and ventilation and to facilitate pulmonary toilet.  Regional aesthesia techniques can be discussed with the pediatric pain team. 
•         Operative treatment is rarely indicated but can be considered for flail segments and severely depressed sternal fractures.

• Blunt Cardiac Injury (BCI)

•          Blunt cardiac injury is rare.
•          Clinical signs consistent with BCI include chest pain, shortness of breath, muffled heart sounds, dysrhythmias and unexplained hypotension in association with chest wall trauma.4
•         Diagnostic tests include ECG, echocardiography, and enzyme analysis.
•         Guidelines for using diagnostic tests are as follows:
•       Level 1 evidence supports obtaining an ECG in the emergency department for at-risk patients5 Using any ECG abnormality, including sinus tachycardia, bradycardia conduction delays and PAC’s/PVC’s, the diagnostic sensitivity of ECG is 100%.6
•      Echocardiography is not effective as a screening tool.7
•      Transthoracic (TTE) or transesophageal echocardiography (TEE) should be obtained in patients with evidence of hemodynamic instability or in whom coincident coronary ischemia is suspected.
•         cTnI is of little added benefit in patients with a markedly abnormal ECG (diagnosis is already made).10
•        Though the utility of cTnI in patients with normal ECG’s is limited, cTnI obtained 4-6 hours after the injury in patients with sinus tachycardia or non-specific EKC changes or in older patients may give reassurance that the likelihood of BCI-related complications is low. 10
• ·      Definitive treatment depends on the specific injury identified.
•       Mainstay is typically supportive care and treatment of arrhythmias.
•       Coronary artery injuries may require percutaneous stenting or operative revascularization.
•       Traumatic septal defects will generally require surgical closure

Thoracic Aortic Injury

• The majority of thoracic aortic injuries occur in the descending aorta at the ligamentum arteriosum due to high energy deceleration. 
• Children may be protected d/t higher compliance of chest wall, lack of atherosclerosis and more flexible vessel histology
•  High risk signs and symptoms include

• Mid-scapular back pain 
• Unexplained hypotension

• Upper extremity hypertension
• Bilateral femoral pulse deficits
• Large initial chest tube output
• Abnormal CXR findings that raise suspicion for thoracic aortic injury include:

o   Upper mediastinal widening

o   Indistinct aortic contour

o   Obscuration of the aortopulmonary window

o   Widened left paraspinal stripe

o   Deviation of the NG tube or trachea to the right

o   Depression of the left mainstem bronchus

o   Left apical cap (apical capping)

 

 

References:

 

1.       Fulda G, Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM, Cowley RA. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979–1989). J Trauma 1991;31(2):167-73.

2.       Miller FB, Shumate CR, Richardson JD. Myocardial contusion. When can the diagnosis be eliminated? Arch Surg 1989;124(7):805-8.

3.       Pasquale NK, Clarke J. Screening of blunt cardiac injury.1998. The Eastern Association for the Surgery of Trauma. Available: http://www.east.org/tpg/chap2.pdf

4.       Fabian TC, Cicala RS, Croce MA, Westbrook LL, Coleman PA, Minard G, et al. A prospective evaluation of myocardial contusion: correlation of significant arrhythmias and cardiac output with CPK-MB measurements. J Trauma 1991;31(5):653-60.

5.       Karalis DG, Victor MF, Davis GA, McAllister MP, Covalesky VA, Ross Jr JJ, et al. The role of echocardiography in blunt chest trauma: a transthoracic and transesophageal echocardiographic study. J Trauma 1994;36(1):53-8.

6.       Fabian TC, Cicala RS, Croce MA, Westbrook LL, Coleman PA, Minard G, et al. A prospective evaluation of myocardial contusion: correlation of significant arrhythmias and cardiac output with CPK-MB measurements. J Trauma 1991;31(5):653-60.

7.       Salim A, Velmahos GC, Jindal A, Chan L, Vassiliu P, Belzberg H, et al. Clinically significant blunt cardiac trauma: role of serum Troponin levels combined with electrocardiographic findings. J Trauma 2001;50(2):237-43.

8.       Collins JN, Cole FJ, Weireter LJ, Riblet JL, Britt LD. The usefulness of serum Troponin levels in evaluating cardiac injury [discussion]. Am Surg 2001;67(9):821-6.

9.       Mirvis SE, Bidwell JK, Buddemeyer EU, et al.  Imaging diagnosis of traumatic aortic rupture:  A review and experience at a major trauma center. Invest Radiol 1987;22:187-190.

10.   Ayella RJ, Hankins JR, Turney SZ, et al.  Ruptured thoracic aorta due to blunt trauma. J Trauma 1977;17:199-204.

11.   American Pediatric Surgical Association.  Not A Textbook.

Disclaimer

These guidelines are not intended as a directive or to present a definitive statement of the applicable standard of patient care.  They are offered as an approach for quality assurance and risk management and are subject to (1) revision as warranted by the continuing evaluation of technology and practice; (2) the overall individual professional discretion and judgment of the treating provider in a given patient circumstance; and (3) the patient’s willingness to follow the recommended treatment.