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CHAPTER 28

Thoracic Trauma

AB (Sebastian) van As
Dorothy V. Rocourt
Benedict C. Nwomeh

Introduction Clinical Presentations
The physiological constitution of children differs substantially from Chest Wall Injuries
that of adults. As a result, injured children often require specific man- The elasticity and flexibility of a child’s chest cage often protect the
agement as compared to adults. This chapter focuses on the manage- child from a serious injury. If rib fractures do occur, however, this is
ment of chest trauma. 1–3 usually a sign of a major energy transfer to the child’s chest and often
Chest injuries occur commonly in children and include damage indicative of a high-velocity injury. A flail segment is an unusual event
to the chest wall, diaphragm, lungs, and mediastinal structures. The in a child, and the underlying pulmonary contusion is much more
presence of chest injury often portends involvement of other organs, important for the prognosis than the flail segment itself.
reflecting the transmission of substantial force to the child’s compact Rib fractures are extremely painful because immobilisation is
body. The severity of chest trauma in children ranges from minor practically impossible. Therefore, adequate analgesia is of the utmost
to rapidly fatal. It is therefore imperative to promptly diagnose and importance to render the child pain-free and to ensure adequate
appropriately treat these injuries to ensure an optimal outcome.
breathing. Intravenous morphine is the drug of choice (as bolus:
Anatomic Considerations 0.1 mg/kg body weight). Oral analgesia is not often tolerated, and
The chest wall in children is elastic; therefore, energy can be transmit- intramuscular (IM) or subcutaneous drugs often are poorly absorbed.
ted to underlying organs without breaking the protective ribs. Severe Respiratory exercises are essential in the proper management. In the
pulmonary contusion or injuries to spleen and liver can occur without case of multiple rib fractures, admission to a specialised trauma unit
overlying rib fractures. Rib fractures and mediastinal injuries are dis- with availability of continuous chest physiotherapy is preferred.
tinctly uncommon in children, and when present they usually indicate Traumatic Asphyxia
the transfer of a massive amount of energy; multiple serious organ Traumatic asphyxia usually occurs as a result of major chest and some-
4
injuries should be suspected. The mediastinum is highly mobile in times abdominal trauma. The exact pathophysiology is not clearly
5
children, and a tension pneumothorax can develop rapidly. understood, but the proposed mechanism is a closed glottis and tensed
Resuscitation abdominal muscles, causing the force of the injury to be transferred to
All resuscitations should strictly follow the general ABC pattern of the superior vena cava and to the head and neck, with subsequent rupture
basic life support, as discussed in Chapter 27. of the superficial blood vessels. Usually, the child presents tachypnoeic
with petechiae over the face, neck, and chest. Additionally, the face might
Demographics be blue and swollen, and retinoscopy might reveal retinal haemorrhages.
Chest injuries are the leading cause of childhood injury death. Children suffering from traumatic asphyxia should be very carefully
Approximately one million children globally die annually as a result of examined for underlying injuries of the vital organs. Treatment should
trauma. The most common cause of trauma is motor vehicle crashes. be symptomatically; however, because these children are likely
Thoracic trauma in children may be classified by mechanism, anatomi- to develop respiratory insufficiency, they should be managed in a
cal site, and severity (immediately or potentially life threatening). The paediatric intensive care unit (PICU). Long-term follow-up of isolated
vast majority of thoracic injuries result from blunt trauma, usually traumatic asphyxia has proven to have an excellent prognosis.
inflicted to a child pedestrian by a motor vehicle. Less than 5% are Tracheobronchial Injuries
attributable to penetrating injuries. Like oesophageal injuries, tracheobronchial injuries are rare. Rupture
Penetrating chest trauma in children, just as in adults, is often the of the trachea or bronchae is usually complete, associated with vascular
result of knife stabs or gunshot wounds. These include BBs or pellets and oesophageal injuries, and occurs mostly within 2.5 cm from the
fired from recreational air guns that can produce life-threatening carina. Proper airway management takes priority; the injuries can usu-
injuries. Other unusual causes of penetrating trauma seen in children ally be repaired primarily via a thoracotomy.
12 years of age or younger include impalement onto shards of broken In the event of a tracheo-oesophageal injury, it is crucial to establish
glass or metal rods. a muscular or pleura flap between the injuries to prevent a fistula.
Most chest injuries occur as a part of multiple injuries, including Lung Injuries
head and abdominal injuries, and it is these associated injuries that
expose these children to a high mortality. It is therefore crucial to Lung contusion is one of the most common childhood chest injuries,
assess the whole patient in the case of a chest injury. Paediatric trauma followed by infection and haematoma. It occurs in approximately
scores may help to identify mortality early in this patient population to two-thirds of all cases of chest trauma. Usually, it results from a rapid
facilitate and expedite treatment. acceleration/deceleration injury (primarily motor vehicle collisions).
Contusions occur within minutes after the injury, are mostly localised
to a (lower) segment or lobe of the lung, and can be diagnosed on the
initial chest radiograph.