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Traumatic Asphyxia If] Chilaten Traumatic asphyxia if] chilaten H.SARIHAN*, M. ABES*, R. AKYAZICI*,A. CAY*, M. IMAMOGLU*,1. TASDELEN*, EIMAMOGLU** . dren with traumatic asphyxia were evaluat- From Departments of Pediatric Surgery spectively. There were five boys and three and Ophthalmology e mechanism of injuries was motor vehicle Karadeniz Technical University ts in six children. A fall in one patient and Faculty of Medicine Trebzon, Turkey ssion by lift in one patient. Clinical features atic asphyxia developed in all patients. Five s were disoriented and consciousness. ed injuries were noted in all patients often thorax and head. Cerebral seizures compli- ad injury in one patient. No mortality was tain, it is a rare pathology. The TA is usually self- limited and resolves over a period of several weeks without complications.e However, the patients with s: Asphyxia, traumatic - Blunt injuries c Child. TA have most commonly associated injuries and morbidity and mortality of these patients related to clinical syndrome characterized by subcon- the severity of these associated injuries." In this ctival hemorrhages, facial edema, and cya- study, we retrospectively evaluated eight patients ombined with ecchymotic petechial hemor- with TA and clinical signs, severity of injury, asso- on the upper chest, neck, face and subcon- ciated injuries; neurologic status, morbidity, mortal- 1 is called, traumatic asphyxia (TA).1-4These ity and long-term follow-up are discussed. st observed by Ollivier in 1837; he termed rome «masque ecchymotiques-when noting aracteristic features in a patient trampled to Materials and methods y crowds in Paris.> Perthese in 1900 fully ed the clinical syndrome.? Many other We reviewed the medical records of eight have been used to describe this syndrome: patients consecutively evaluated at the Faculty of ic cyanosis, compression cyanosis. Perthes Medicine, Departement of Pediatric Surgery, jn complex, cervico-facial cutaneous Trabzon, with traumatic asphyxia between June fa, and cervicofacial static cvanosis.s The 1992 and October 1995. All diagnoses were con- mmon causes of TA are direct compression firmed clinically. chest wall or upper adbomen due to blunt After patients were stabilized in the emergency . Other etiological factors are epileptic sei- room including intubation if required.jintravenous vomiting, whooping cough, bronchial asth- fluids and blood transfusion, chest radiography, p-sea diving and difficult obstetric deliver- and ultrasonographic and computed tomographic examinations were performed. If necessary chest ugh the incidence of TA is difficult to ascer- drainage was performed in the emergency room. After strict examinations all patients were admitted s', address: H. Sarihan, Department of Pediatric Surgery, to the intensive care unit. Z Technical University, Faculty of Medicine, 61080 Trabzon, Charts were carefully reviewed for age, sex, spe- THE JOURNAL OF CARDIOVASCULAR SURGERY 93 SARIHAN TRAUMATIC ASPHYXIA IN CIiIL]) loskeletal in four, hemothorax in two, pneumot rax in two, and hepatic and splenic injuries in patients. Cerebral CT examinations were performed in patients and cerebral edema and/or hemorrha were noted in six patients. All patients were succesfully treated conse tively including broad spectum antibiotics oxy mask, steroids and bed rest. One patient requi intubation and mechanical ventilation. Chest dr£ age was performed in three patients due to he thorax and/or pneumothorax. Two patients w intra-abdominal bleeding were also treated non eratively. The average period of hospitalization was 1 Fig. 1.- Typical appearance of traumatic asphyxia in a nine year days, with a range of 2 to 42 days. Cutane old girl. lesions and subconjunctival hemorrhage were 1 between eight and twenty days. Complicati cific details of the accident, clinical status, associat- during hospitalization occurred in one patie ed injuries, duration of hospital stay, management, with cerebral seizures due to head injury. Ot complications and mortality. seven patients were followed up for six mont and two years. There was no persisting physic or mental disabilities resulting from or attrib able to their injuies. No mortality was noted Results our cases: The patients ranged in age from 2.5 to 12 years (mean, 6.9 years); five were males, and three were Discussion and conclusions girls. Motor-vehicle accidents caused the injuries in six children (four was compressed by a wheel, and Traumatic asphyxia is, for the most part, seen: two were run down). One patient fell from the fifth children with their elastic walls. It occurs only w floor and one patient was compressed by lift. sudden severe crushing forces. Most reported ca Clinical features such as cervicofacial cyanosis of TA result from anterior-posterior compression and petechiae of the head and neck regions, facial the victim'S chest and/or upper abdomen. The u edema, and subconjunctival hemorrhages devel- al cause of TA includes motor vehicle accidents, oped in all patients in varying degrees (Fig. 1). which the patient is compressed by the wheel. Tachypnea and dyspnea were noted in five The amount of force required and duration. patients. Five patients were disoriented and con- application to produce the typical manifestation sciousness.Four patients were in shock because TA is not know. Weights ranging from 3000 POUB two had hemothorax and two had associated to several tons have been recorded and the typf abdominal trauma. Fundoscopic examination was range of compression is between two and five rni performed in all patients and two patients had disc utes.311 hemorrhages, two patient had venous congestion, The pathophysiology of TA involves four fact an four other patients had normal fundi. 1) deep inspiration, 2) closure of the glottis, Associated injuries were noted in eight patients. thoracoabdorninal effort, eg, splinting of thora Seven patients had pulmonary contusion, six arid abdominal musculature, and 4) thoracic patients had head injuries, five patients had rib abdominal compression.> Following compressi fractures. Pneumomediastinum and extensive sub- of the chest or upper abdomen, pressure is tra cutaneous emphysema were noted in three mitted to the mediastinum and then to valvel patients. Other associated injuries included museu- superior vena cava into the head and neck 94 THE JOURNAL OF CARDIOVASCULAR SURGERY February 1 TIC ASPHYXIA IN CHILDREN SARIHAN quent disruption of superficial capillaries. no specific therapy. The patients are observed in st compression produces varying amounts of an intensive care unit initially. When pulmonary ta: and hypoxia, which may contribute to con- contusion and/or cerebral edema are noted steroid Gh of the abdominal, sympathetic nerves caus- treatment should be performed. If there is hemo- . sodilatation of the head and neck region and thorax and/or pneumothorax chest drainage is per- of the small vessels.i» Experimental studies formed. Associated abdominal injuries may require :nstrated that occlusion of the superior vena surgical intervention.t> lone could cause a considerable congestion The prognosis for TA is very good despite the upper extremities and head regions without alarming initial physical appearance.> 3 8 The lesion nical features of TAJ Williams et al.12 demon- is usually self lirnited and resolved over a period of that chest compression for 30 seconds at several weeks.? Neurological lesions are transient spiration with a closed glottis produced an and most recover within 48 hours.s 56 Neurological rise in jugular venous pressure, 8.8 times sequelae are rare and are related to associated than the control group, however when cerebral injury.?In our series neurological sequelae ompression occurred with an open glottis de-veloped in one patient due to associated cere- venous pressure rose only 1.5 times over bral injury, and no long-term disability was noted trol group in dogs. They proposed that the at a mean of 2.5 years follow-up in other seven glottis with TA is closed due to fear reflex patients.Mortality is rarely related to TA. In fatal during trauma.is cases, compression had been prolonged.? It is pro- I clinical findings of TA are petechiae cover-- posed that prolonged compression restricts chest -face, neck, and upper chest as well as sub- wall motion producing apnea, hypoxia, and death. ctival and retinal hemorrhages. The face and 2 Mortality in our series was nil. 'e usually blue and swollen. Below the level ct the skin is normaJ.1-5 At fundoscopy reti- orrhage may be eviderit.rv Immediate References ent or loss of vision has also been reported 1. Erdener A., Balik E, Cetinkursun S, Ilhan H. Traumatic asphyxia ult of retinal edema, but may promptly in childhood. J Turkish Pediatr Surg 1989;3:33-5. within hours or days.w Pulmonary and/or 2. Gorenstein L, Blair GK, Shandling B. The prognosis of traumat- ic asphyxia in childhood. J Pediatr Surg 1986;21:753-6_ ssels injuries are evident.ra pneumothorax 3. Haller JA, Jr. Thoracic injuries. In:Whelch KJ, Randolph JG, emothorax, mediastinal air, subcutaneous Ravitch MM et al., editors. Pediatric Surgery. Chicago: Yearbook Medical Publishers 1986;1:143-54. erna and hemoptysis may be seen.> 8 11 4. Jones MJ, James EC.The management of traumatic asphyxia: es, 'venous pressure is transmitted into the case report and literature review. J Trauma 1976;16:235-8. _ ominal viscera via the inferior vena cava 5. Lee MC,Wang SS, Chu JJ et al. Traumatic asphyxia. Ann Thorac -ltt" - Surg 1991;51 :86-8. atemesis, rectal mucosal bleeding, hematu- 6. Landercasper J, Cogbill TH. tong -term follow-up after traumat- lbuminuria may also occur.s e ic asphyxia. J Trauma 1985;25:838-41- logical symptoms are often associated with 7. Reichert FL, Martin JW. Traumatic asphyxia, experimental and clinical observations with a report of a case with concomitant 'patients are usually disoriented, agitated paraplegia. Ann Surg 1951;134:361-6. [tless. Loss of consciousness has been 8. Reynolds M. Pulmonary, esophageal, and diaphragmatic inju- ries.In: Buntain WL, editor. Management of pediatric trauma. , in 33% of patients." These neurological Philadelphia: WB Saunders Company 1994:238-47 .
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