Thoracic Trauma in Children - An Overview

Introduction

The fundamental assessment of a patient who has sustained an injury adheres to the principles taught in the advanced trauma life support curriculum, irrespective of the individual's age. The primary survey is a crucial step in establishing a systematic approach to treatment and identifying life-threatening conditions in patients with severe injuries. In the case of thoracic trauma, the ABCs of the primary survey may be disrupted, highlighting the potential for life-threatening injury.

What Is Thoracic Injury in Children?

• Thoracic injury in children needs particular consideration due to morbidity and mortality despite its representation of less than ten percent of traumatic injuries in this population.

• Chest trauma has been identified as the second leading cause of mortality in children who have sustained traumatic injuries. Furthermore, chest trauma in pediatric patients is a prognostic factor for heightened mortality rates.

• Although children have a smaller body surface area, which leads to concurrent abdominal injuries, thoracic injuries exhibit a 20 percent higher likelihood of being linked to mortality compared to abdominal injuries. Incidences of chest penetrating injuries in pediatric patients are infrequent and have not been encompassed in the present analysis.

Chest wall injuries, hemothorax (a buildup of blood in the space between the abdominal and attaches to the chest wall) pneumothorax (collapsing lung), and pulmonary parenchymal injury are frequently encountered in pediatric thoracic injuries; this review will provide a succinct overview of the less common injuries of the tracheobronchial tree, great vessels, heart, esophagus, and diaphragm, due to their elevated morbidity and mortality rates.

How Can the Injuries Occur To the Diaphragm Managed?

Diaphragmatic injuries are uncommon, but when they happen, the left side is affected more often than the right because the liver protects the right side.

• Children complain of belly discomfort, chest pain, shoulder pain, missing breath sounds on the injured side, bowel sounds in the chest, and respiratory distress.

• Chest X-rays can diagnose the condition, but more imaging may be required because these injuries sometimes worsen over time.

• A routine chest X-ray does not exclude the injury either, so in patients who have a suspicion of diaphragmatic injury but no obvious evidence on the X-ray, a chest CT with oral contrast can confirm the diagnosis.

• Laparoscopy or thoracoscopy can also be used for diagnosis and treatment.

• Operative repair is often performed using a thoracic approach in the delayed situation and an abdominal approach in the acute setting. These wounds can be treated in a stable patient using minimally invasive methods (laparoscopy or thoracoscopy).

How Can Cardiovascular Injury Be Managed?

• Children are less likely than adults to have heart or great vascular injuries, which are rarer. One to seven percent of kids who have thoracic trauma experience thoracic aortic damage, and even fewer kids—0.3 to four percent—experience blunt cardiac injury.

• Significant mortality results from these injuries, with blunt aortic trauma having a six-hour mortality rate of 30 percent and cardiac trauma having a 24-hour mortality rate of 40 percent.

• First rib and sternal fractures, paraplegia (leg paralysis without arm involvement), hypertension in the upper extremities, and differences in the pulse or blood pressure in the extremities are all symptoms that children with thoracic aortic injury present with.

• Children having an aortic injury should have a CT scan with IV contrast done. The chest X-ray findings of the enlarged mediastinum or the disappearance of the aortic knob can confirm aortic injury. Intravascular ultrasonography and transesophageal echocardiography are further options. Although endovascular stent grafts are less desirable in growing children, prompt surgical intervention with either open or endovascular techniques is necessary. Aggressive blood pressure control should also be undertaken before surgery.

Depending on the severity of the injury, a blunt cardiac injury might manifest as asymptomatic electrocardiography abnormalities, arrhythmias(Irregular heartbeats), or severe hemodynamic compromise. Any patient with alterations in electrocardiography or symptoms should have echocardiography performed, and supportive care should continue.

How Can Lung Injury Be Managed?

• The comparatively weak and compliant chest wall transmits force to the underlying organs, causing pulmonary contusions, lacerations or cuts, and traumatic pulmonary lesions in infants.

• Pulmonary contusions occur in 34 to 100 percent of children with thoracic trauma, ranging from asymptomatic radiography findings to severe respiratory failure needing mechanical ventilation. Pulmonary bleeding and edema or swelling from pulmonary injury hinder gas exchange.

• Chest X-rays can detect clinically minor pulmonary contusions.

• Ultrasonography can diagnose pulmonary contusion. Several hours after damage, a severe pulmonary contusion may occur despite a negative chest X-ray. Minor pulmonary contusions require supplementary oxygen, pulmonary toilet, and fluid restriction, while severe contusions may necessitate mechanical breathing in up to 30 percent of children.

• High positive end-expiratory pressures, inhaled nitric oxide, high-frequency oscillating ventilation, and extracorporeal membrane oxygenation may help maximize gas exchange.

• Most children with pulmonary contusions recover spontaneously and have normal lung function.

• Traumatic pneumatoceles are usually asymptomatic and identified by chest X-ray or CT scan. They vary in size and usually require only expectant treatment and a repeat chest X-ray to show a lesion reduction, as they might grow for several days after injury. Surgery is needed if they grow large enough to impair breathing.

How Can Tracheobronchial Injury Be Managed?

Fewer children experiencing thoracic trauma have tracheobronchial tree injuries. The pressure of the compliant chest wall presses the sternum on the spine, causing lung displacement and bronchi damage.

• Thoracic trauma can cause direct tracheal injury or tracheobronchial injury through fast intratracheal pressure rise against a closed glottis.

• Asymptomatic patients or those with pneumothorax (an accumulation of air within the pleural cavity that is located outside the lung), hemothorax (when patient simultaneously have air and blood in pleural space), pneumomediastinum (the presence of air in the mediastinum, the area between the two lungs in the chest), hemoptysis (when blood is coughed up from the airways), subcutaneous emphysema (the formation of new air or its entry into the skin beneath the dermal layers), and respiratory discomfort may delay diagnosis.

• When a substantial air leak persists after tube thoracostomy and flexible bronchoscopy, the diagnosis is done to verify the damage. Bronchoscopy locates and assesses the damage and helps in guiding the treatment.

• The child can be managed nonoperatively if the patient maintains respiratory stability by securing the airway and emptying the pneumothorax when the lesion involves less than a third of the tracheal diameter.

• For the success of the procedure, thoracotomy, and operative repair must be tension-free and reinforced with a vascularized tissue flap.

How Can Esophageal Injury Be Managed?

Children suffer esophageal perforation from blunt thoracic injuries, causing difficulty in diagnosing associated injuries.

• The occurrence of esophageal injuries is low with blunt injury, and the associated signs and symptoms often present in a delayed and nonspecific manner, especially if the injury is contained.

• After acute thoracic trauma, esophageal perforations are accompanied by nonspecific neck and chest discomfort, dyspnea (shortness of breath), fever, crepitation (a sensation of crunching experienced in specific medical conditions), subcutaneous air on plain film, pneumomediastinum, and infrequently pleural effusions (atypical accumulation of fluid surrounding the lung.) and pneumothoraces (a collapsed lung).

• Esophageal injuries are typically misdiagnosed since these signs are generic and might be observed in different thoracic injuries.

• A high index of suspicion is needed, and full diagnostics should be done for esophageal injury or already diagnosed mediastinal injury.

• Patients with injuries to the cervicothoracic esophagus, the most common site of esophageal injury, have an almost 60 percent incidence of tracheolaryngeal injury.

• Injury suspicion persists, and a previously negative diagnostic workup must be redone due to the possibility of a delayed presentation, up to 74 days in one pediatric case report.

• A water-soluble esophagram is the first diagnostic step for esophageal injury to diagnose any perforation; it avoids barium sulfate contrast's potential inflammatory reaction.

• A negative report should be repeated with barium sulfate diagnosis due to its 10 to 38 percent false negative rate.

• However, a negative contrast examination should be followed with an endoscopy. Endoscopy can be the first diagnostic study depending on the patient's stability and ability to be transported to the fluoroscopy suite. The contrast study can be used as a complementary diagnostic modality if negative.

• Flexible endoscopy has a lower complication rate than rigid endoscopy, but rigid endoscopy has a higher sensitivity.

• Pediatric trauma surgeons utilize rigid esophagoscopy. Instead of or in addition to a negative fluoroscopic examination, CT esophagography using low-osmolar IV contrast material as the oral contrast agent has been suggested.

• This method screens for esophageal injury and other trauma-related thoracic injuries that may cause the patient's symptoms.

• For stable patients with confined leakage, nonoperative therapy should be used after diagnosis. Primary esophageal repair with live tissue reinforcement is best for those who fail nonoperative therapy.

Conclusion

Thoracic trauma patients need to have thorough examinations with other systems. Brain imaging is especially important because a quarter of individuals with thoracic trauma can be seen to have head injuries. It was discovered that the development of rib fractures was a risk factor for hemothorax. The mortality rates were widespread before the age of four, while mortality rates from external sources were high in individuals between ten and 18 years. Thoracic surgeons who treat pediatric trauma patients should be familiar with children's anatomy regarding their age—rapid arrival at the hospital and prompt, precise patient intervention lower death and morbidity rates. Trauma patients who can be operated on may do better.