Thoracic Trauma
Kenneth F. Newcomer
Trauma is a leading cause of death in children and young adults.
It has been estimated that almost 25% of deaths are attributed to some type of chest trauma and the vast majority are from blunt injury.1
Most frequent causes of chest trauma include motor vehicle crashes, falls, and pedestrian and sports injuries.1
RELEVANT ANATOMY AND PHYSIOLOGY
Compared with adults, the chest wall of children has a greatly increased compliance, transmitting more force to internal structures.
Occurrence of rare but deadly injuries such as commotio cordis and traumatic asphyxia is also attributed to increased chest wall compliance.2
A mobile mediastinum in children makes them particularly susceptible to shift, notably in tension pneumothorax.
Physiology: A higher rate of tissue O2 consumption in children makes children prone to hypoxia.
Increased heart rate is able to maintain arterial pressure, despite severe intravascular volume loss, but can rapidly decompensate.
Hypothermia is a concern because the body volume to surface area ratio is smaller than adults.
EPIDEMIOLOGY AND ETIOLOGY
Incidence: It varies from approximately 4% to 25% in trauma patients.3
Thoracic trauma is a marker of severe injury in pediatric patients and has increased mortality when combined with head and abdominal trauma (25%) and central nervous system trauma (40%).3,4
Blunt mechanisms account for 80% to 95% of pediatric thoracic trauma.
Etiology: Motor vehicle accidents are the most common etiology for blunt trauma. Gunshots cause most penetrating trauma.
Most common injuries: They include pulmonary contusion, rib fracture, and pneumothorax.
COMMON INJURY PATTERNS
Chest Wall Injury
Rib fractures, especially first rib fractures, are suggestive of high-energy trauma and should prompt an investigation for intrathoracic injury (Figure 9.1).
Rib fracture in children aged 0 to 3 years is suspicious for nonaccidental trauma (especially posterior rib fractures).
Open pneumothoraxes (sucking wounds) can cause rapid mediastinal shift and are treated with chest tube and occlusive dressing.
Pain management and breathing exercises are the mainstay of treatment for all rib fractures.
Pulmonary Injury
Contusion is a common injury and may occur in the absence of rib fractures.
Severe contusion can lead to respiratory failure or acute respiratory distress syndrome.
Traumatic pneumothorax is typically managed with a chest tube.
Hemothorax and hemopneumothorax are associated with higher mortality but are also typically managed with chest tube.
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