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Chest Trauma in Children

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Chest Trauma in Children Chest Trauma In Children Donovan Dwyer MBBCh, DCH, DipPEC, FACEM Emergency Physician St George and Sydney Children’s Hospitals Director of Trauma, Sydney Children’s Hospital Disclaimer • This cannot be comprehensive • Trying to give trauma clinicians a perspective on paediatric differences • Trying to give emergency paediatric clinicians a perspective on trauma challenges • The format will focus on take home salient points related to ED dx and management • I may gloss over slides with more detail and references to keep to time • As most chest mortality is in the 12-15 yr age group, where paediatric evidence is low, I have looked to adult evidence OVERVIEW • Size of the problem • Common injuries – pitfalls and tips • Less common injuries – where recognition and time is critical • Blunt vs penetrating • The Chest in Traumatic Cardiac Arrest Size of the problem • Overall paediatric trauma in Australasia is low volume • Parents take injured children to nearest hospital for primary care • Prehospital services will divert to nearest facility with critically injured children Chest Injury • RV of Victorian State Trauma Registry in 2001–2007 = 204 cases • < 1/week • Blunt trauma - 96% • motor vehicle collisions (75%) • pedestrian (26%) • vehicle occupants (33%) Size of the problem • Common injuries – combined 50% of the time • lung contusion (66%) • haemo/pneumothorax (32%) • rib fracture (23%). • Associated multiple organ injury 90% • head (62%) • abdominal (50%) • Management conservative/supportive > 80% • Surgical • 11 cases (7%) treated surgically • 30% invasive • 18 cases(11%) had insertion of intercostal catheters (ICC). • Epidemiology of major paediatric chest trauma, Sumudu P Samarasekera ET AL, Journal of Paediatrics and Child Health (2009) International • 85 % Blunt –MVA – 45% • Ped vs car – 20% • Falls – 10% • NAI – 7% • Penetrating 15% • Mortality • Cooper A. Thoracic injuries. Semin Pediatr Surg. 1995 May. • Blunt • Chest alone - < 5% • Combined – 16-40% (14% chest cause) • Penetrating • 14% mortality (97% chest cause) Summary • Chest trauma is relatively common, but more commonly associated with other injuries • Common presentations need ventilatory support +/- ICD • Acute invasive Surgical intervention is infrequent • There are some time critical conditions that need early recognition • Mortality comes from co-existant injuries mostly in blunt trauma, but almost entirely from the chest in penetrating trauma With regard to lung contusion which is false? 1. Lung contusion is an early finding on CXR 2. Chest CT should follow a finding of pulmonary contusion on CXR 3. Ventilatory support is the most frequent intervention 4. Associated pulmonary haemorrhage can be significant Lung Contusion +/- Rib fracture +/-flail chest • Most common thoracic injury - > 60% in most series • Rib fractures in less than 30%, but indicate significant force • Usually recognised early on CXR (>90%), aspiration usually later • CT not routinely indicated = low yield, expensive, significant radiation • Complications • ventilatory insufficiency • Pneumonia • ARDS • Blood loss • Management – supportive • ECMO • Should helical CT scanning of the thoracic cavity replace the conventional chest x-ray as a primary assessment tool in pediatric trauma? An efficacy and cost analysis. Renton J et al, J Pediatr Surg. 2003 May. • Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. Holscher CM et al. J Surg Res. 2013 Sep • Isolated computed tomography diagnosis of pulmonary contusion does not correlate with increased morbidity. Kwon et al.8 2006 , J Pediatr Surg. 2006 With regard to traumatic pneumothorax…which is true? 1. All traumatic pneumothoraces should have a large bore ICC placed 2. Younger children are less susceptible to compromise from tension pneumothorax c/w older children 3. Tension pneumothorax should be a clinical not radiological diagnosis 4. CXR is recommended before ICC placement in stable patients.. Pneumothorax • Pneumothorax may result from • puncture of the lung by a rib • penetrating chest wall injury • disruption of the pulmonary parenchyma • injury to the tracheobronchial tree. • Mediastinal shift greatest with young, more rigid and less deformable with age • Tension Ptx less well tolerated in young • Radiological tension not an uncommon finding in relatively stable child – tachycardia, mild desaturation ICC • If isolated Ptx with indication to place ICC – small bore ICC less painful, safer, equivalent success • Adult evidence suggesting small bore pigtail efficacious in stable haemothorax • If suspicion of assoc. haemothorax, unstable – recommendation of large bore (standard) ICC. • Diagnostic overcalls – resulting in unnecessary ICC • Diaphragmatic hernia • Gastric distension • Misplaced ETT • Cardiac tamponade • Hypovolaemia • CXR advised prior to ICC placement if stable • Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax , N. Kulvatunyou, British Journal of Surgery. 101(2):17-22, January 2014. With regard to isolated occult traumatic pneumothorax… which is true? 1. It should be confirmed on CT if suspected 2. An ICC should be placed if the child is to have PPV 3. It is frequently associated with rib fractures and occult haemothorax 4. The ‘black stripe sign’, ‘deep sulcus sign’ may suggest a pneumothorax is present.. Occult Ptx • Ptx found on CT cspine, chest or abdo, but not present on CXR • Occult less likely to have rib fractures, haemothorax • Safe to observe – clinically • Very few require ICC • Consider repeat CXR if clinical indication, no role for CT • A number of adult and paediatric studies support the safety of non intervention even with PPV ‘Occult Ptx’ Black stripe sign Deep sulcus sign • Pneumothorax – diagnostic pitfalls, Sur, Brandon et al, Contemporary Diagnostic Radiology. 38(4):1-7, February 15, 2015 Traumatic pneumomediastinum, which is false? 1. In high velocity/impact trauma it is associated with significant injury 2. Can represent abdominal traumatic pathology 3. Once discovered necessitates a CT 4. Has a warranted aggressive investigative approach in penetrating injury 5. Is rare (1-2%) and mostly benign.. Pneumomediastinum • Approx 1-2 % of all chest trauma • Possible causes • Alveolar rupture – most common – ‘Macklin effect’ • Tracheobronchial injury– rare 1-2% • Oesophageal injury - v .rare • Ix – Blunt • Low yield for CT – but confirms occult Ptx or mediastinal air - best for tracheobronchial • Routine bronchoscopy/oesophagoscopy/contrast study not indicated • Ix – penetrating • CT +/- exploration/contrast studies • Pneumomediastinum following blunt chest trauma – worth an exhaustive work up? Chouliaras, K MD et al; Journal of Trauma and Acute Care Surgery. 79(2):188-193, August 2015. • Presence of pneumomediastinum after blunt trauma in children: what does it really mean? Neal MD, etal; J Pediatr Surg. 2009. Blunt Trauma Haemothorax. Which is true? 1. Is easily detected on supine trauma CXR 2. Can have bleeding and blood volume loss accurately monitored with an ICC 3. When draining a haemopneumothorax the ICC should have a ‘3 bottle UWSD’ attached 4. Has a low rate of empyema and other complications if not drained Blunt Haemothorax • Haemothorax may result from • injury to any of the intrathoracic vessels or the lung parenchyma • traumatic rib fracture may lacerate intercostal arteries or veins • More rarely, mediastinal vessels such as the vena cava or aorta may be disrupted by pressure or shear forces. • Diagnostic and monitoring challenges – • Often asymptomatic, unless the volume is large (40% blood loss) • Diagnosis in supine patient • Quality of CXR – immobilisation devices, clothes • Chest tube challenges • Blockage with clot/lung • Positioning – fissure, anteriorly • Does CT modify mx of traumatic haemothorax, David, J.-S.; Acta Anaesthesiologica Scandinavica. 50(5):640-641, May 2006 • Pediatric thoracic trauma, David Bliss, MD et al,, Crit Care Med 2002 CHEST DRAIN TROUBLESHOOTING Blood CHEST DRAIN TROUBLESHOOTING CHEST DRAIN TROUBLESHOOTING Haemothorax • Increased risks following traumatic injury • Complications • scarring, atelectasis, pneumonia, empyema(33%) • What volume requires ICD? • Small haemothorax after blunt trauma, (1.5 cm on chest CT) can be managed nonoperatively. • Will ICD be efficaceous? • Residual hemothorax after chest tube • VATS • Move to minimally invasive • evacuate residual hematoma • decrease LOS, Ventilator days and risk of empyema • Occult traumatic hemothorax: when can sleeping dogs lie? Bilello et al., Am J Surg. • Karmy-Jones, Can Respir J. 15 year old gunshot right chest, no exit wound. HD stable on arrival. Which is true? 1. Trauma series- CXR and Pelvic Xray should be performed 2. NGT, IDC and PR exam are indicated as adjuncts to the primary survey 3. Insist on Consultant surgical presence once pt becomes haemodynamically unstable 4. If BP drops below 100 give 0.9% NS 20ml/kg bolus to improve BP 10 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0% 0% 0% 0% Trauma series- CXR and NGT, IDC and PR exam Insist on Consultant If BP drops below 100 Pelvic Xray should be are indicated as surgical presence once give 0.9% NS 20ml/kg performed adjuncts to the primary pt becomes bolus to improve BP survey haemodynamically unstable 15 year old gunshot right chest, no exit wound. HD stable on arrival. Which is true? 1. Trauma series- CXR and Pelvic Xray should be performed 2. NGT, IDC and PR exam are indicated as adjuncts to the primary survey 3. Insist on Consultant
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