Symposium on Childhood Trauma
Major Thoracic Trauma in Chi,ldren J. Alex Haller, Jr., M.D. * and Dennis W. Shermeta, M.D. **
Penetrating as well as blunt injuries to the chest occur frequently in adults, but in children penetrating injuries to the chest are rare. 1 Penetrating injuries usually result from fractured ribs or clavicles and not from external missiles.4 Blunt thoracic trauma is much more common in children and often requires immediate correction of functional deficits before anything is known of the mechanism of injury or of the child's previous physical condition.2 Hypoxia and hypotension allow little time for deliberation and consultation. On the other hand, hypotension from blood loss may begin insidiously and continue for long hours with excellent prognosis for complete recovery. Therefore, physicians and paramedical personnel who are responsible for the immediate care of an accident victim with a potential chest injury must be prepared to act according to some preconceived plan of evaluation and triage. In this discussion we propose to outline a course of action,including sequential evaluation, which we have developed in the management of multiple trauma, including blunt thoracic injuries, in the Children's Trauma Center of the Johns Hopkins Hospital. The concept that one person has primary responsibility for the evaluation of an injured child, preferably a pediatric surgeon, is so well established that it probably requires no further amplification. The initial evaluation and initiation of triage do not necessarily imply the presence of a well trained trauma physician, but it does entail the utilization of a nurse or physician substitute with experience in the management of major trauma. Triage and initial evaluation of a patient with blunt trauma may be conveniently divided into three categories which can be simplified to allow maximal utilization of paramedical personnel and junior house officers. These are arbitrary categories and are fluid in nature because the patient's response to treatment may necessitate change in status as the patient undergoes treatment and further evaluation. *Robert Garrett Professor of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland **Chief, Department of Pediatric Surgery, University of Maryland School of Medicine, Baltimore; Assistant Professor of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland Pediatric Clinics of North America- Vol, 22, No.2, May 1975
341
342
J. ALEX HALLER, JR., AND DENNIS W. SHERMETA
Figure 1.
Obstructed right main stem bronchus from aspirated premolar tooth.
Injuries Immediately Life-Threatening An example of a common injury in this category is upper airway obstruction from injury to the oral pharynx which results in aspiration of significant quantities of blood or foreign bodies such as teeth. CASE 1. A nine year old male was noted to have severe upper airway obstruction following trauma to the mouth and face. X-ray of the chest (Fig. 1) revealed a tooth in the right mainstem bronchus which was rapidly removed by endoscopy with immediate relief of respiratory distress.
Trauma to the trachea or bronchus may result in partial or complete rupture, which may result in rapidly increasing subcutaneous emphysema and progressive cyanosis. If initial attempts at endotracheal intubation are not effective, a tracheostomy may be life-saving. CASE 2. Chest x-ray of a four year old child (Fig. 2) who was resuscitated after being strangled by a station wagon back window. Marked mediastinal emphysema is demonstrated.
Intrathoracic hemorrhage may be detected by frequent monitoring of blood pressure and pulse and this potentially life-threatening complication can be quickly diagnosed and treated. Once a continuinghemotho-
MAJOR THORACIC TRAUMA IN CHILDREN
Figure 2.
343
Crushed trachea with marked mediastinal emphysema.
rax is recognized and prompt insertion of a thoracotomy tube effected, persistent drainage of blood is the indication for operative exploration. CASE 3. Depicts the initial chest x-ray (Fig. 3A) of a six year old girl struck by an automobile and admitted to the Trauma Center, semiconscious with obvious respiratory difficulty. Examination revealed slowly decreasing blood pressure and absent breath sounds on the right side. The chest x-ray showed pulmonary contusion and a hemopneumothorax with the mediastinum shifted to the left. A thoracostomy tube was inserted in the right ninth interspace with the immediate drainage of bright, red blood which persisted. Thoracotomy was carried out within a few hours and a laceration into the right lower lobe necessitated a lobectomy. Chest x-ray (Fig. 3B) shows immediate post-tube evacuation and 3C shows return of the initial status after six hours which prompted the decision for a thoracotomy. Figure 3D shows the status 12 days following right lower lobectomy. Most blunt .thoracic trauma is not associated with significant intrathoracic hemorrhage, but a fractured rib may cause major vascular injuries resulting in significant hemorrhage.
Major pulmonary and hilar vessels may be injured by fractured ribs or clavicles, as illustrated by the arteriogram (Fig. 4A) on an 11 year old boy who was run over by an automobile. He was brought to the Trauma Center with a cold, mottled, pulseless right arm and an obvious depressed right clavicular fracture. Elevation of the proximal third of the clavicle improved the appearance of the arm but without return of peripheral pulses. A suspected intrathoracic subclavian artery injury was
344
J.
ALEX HALLER
JR.,
AND DENNIS
W.
SHERMETA
Figure 3. A Traumatic hemopneumothorax and right pulmonary contusion. B Po tevacuation x-ray of hemopneumothorax. C Recurrent hemothorax in spite of thoraco tomy drainage. D Twel e days after right lower lobectomy for uncontrolled hemorrhage.
MAJOR THORACIC TRAUMA IN CHILDREN
345
evaluated by immediate arteriography. The arteriogram demonstrates stretching and spasm of the axillary artery without extravasation or intimal damage. Over the next six hours, the radial pulse returned and repeat arteriogram (Fig. 4B) several days later showed a normal arterial tree. This case illustrates the importance of utilizing arteriography in the evaluation of potential vascular injuries associated with blunt trauma, and also emphasizes the occasional presence of spasm associated with trauma rather than thrombosis or transection. In the management of patients with chest trauma and with potential blood loss and hypotension, we have been loathe to use the standard percutaneous subclavian catheter placement for the monitoring of central venous pressure. Because of the small size of the vessel and the incidence of iatrogenic pneumothorax, we have avoided using this technique to prevent increasing respiratory impairment in a child who already has blunt thoracic trauma. Instead, we have used a direct cutdown on the jugular vein preferring to thread a small Silastic catheter into the right atrium via this route. Since many of these children will, in addition, require large amounts of intravenous fluid in their resuscitation, the presence of a central venous pressure catheter can be a most important means of monitoring this replacement. In addition, such children should have a urethral catheter inserted into the urinary bladder to allow decompression of the bladder and evaluation of the urinary tract for possible associated injuries. Serious Injuries Not Immediately Life-Threatening This type of thoracic trauma is most commonly seen in multiple systems injuries in children. This group includes multiple rib fractures with pneumothorax or small hemopneumothorax. Closed thoracostomy and frequent evaluation of respiratory function including measurement of arterial p02 and pC02 are usually followed by rapid stabilization and recovery of children in a pediatric intensive care unit. The above findings may be associated with significant pulmonary contusion and are treated siInilarly but with the addition of intravenous antibiotic therapy to prevent secondary infection of the intrapulmonary hematoma; Multiple rib fractures with resultant flail chest have infrequently caused ventilatory difficulty in children. If, however, careful monitoring of blood gases indicates ineffectual gas exchange, we have not hesitated to provide positive pressure ventilation through an endotracheal tube for several days. A tracheostomy tube has rarely been necessary, but when indicated, the new plastic tracheostomy tubes have been quite satisfactory with a very low incidence of tracheal stenosis or other local complications. Traumatic asphyxia is also included in this category. Traumatic asphyxia apparently results from sudden compression of the thoracic cage, while the glottis is closed.3 This sudden increase in pressure drives the venous blood into the capillaries resulting in extravasation and hemorrhages in brain tissue may result in loss of consciousness, convulsions, and occasionally other significant neurologic sequelae. As soon as the etiology of the chest compression is relieved, there is a slow but con-
346
J.
ALEX HALLER JR.
A D DE
IS
W.
SHERMETA
Figure 4. A, Percutaneou femoral aortogram for e aluation of ab ent pulse in right arm after cru h injury to right upper che t. ote right cIa icular fracture. B Repeat arteriogram three da after trauma howing complete re olution of a cular pa m .
tinuous subsidence of the petechial hemorrhages with complete resolution common in five to seven days. Injuries to Thoracic Cage and Isolated Pulmonary Contusions This third type of injury is illustrated by the chest x-ray of a nine year old boy who was struck by a baseball in the left anterior chest (Fig. 5A). A large pulmonary contusion strikingly localized is seen with-
Fi ure 5. A, Localized radio den ity in left mid-lung field following ba eball injury of che t. B, Same child two day later howing complete re olution of pulmonary contu ion.
r
MAJOR THORACIC TRAUMA IN CHILDREN
347
out significant impairment of respiratory function or alteration in blood gases. Repeat chest x-ray two days later showed complete resolution (Fig.5B). Our experience with major blunt trauma in children has shown that significant thoracic injuries are frequently a component of multisysterns injuries; and therefore, a proper sequence must be followed in the management of the whole spectrum of multi-organ injuries. Whatever therapy is rendered, it must be aimed toward maintaining satisfactory ventilation and adequate airway and optimal tissue perfusion throughout the course of evaluation and resuscitation. This may require the insertion of a thoracostomy tube prior to the induction of general anesthesia for evacuation of an associated subdural hematoma or an intra-abdominal injury. This type of preventive insertion of a chest tube must be done without hesitation, for if a tension pneumothorax occurs intraoperatively under anesthesia, it may be undetected or discovered too late to provide adequate ventilation. Total evaluation of the child with major blunt trauma is a diagnostic challenge requiring the greatest experience and skill in judgment. A well organized system of evaluation and resuscitation, including the use of monitoring techniques, is necessary for first class treatment of children with major blunt trauma
REFERENCES 1. Bellinger, S. B.: Penetrating chest injuries in children. Ann. Thorac. Surg., 14:635, 1972. 2. Cohn, R.: Non-penetrating wounds of the lungs and bronchi. Surg. Clin. N. Am., 52:585, 19672. 3. Haller, J. A., and Donahoo, J. S.: Traumatic asphyxia in children. J. Trauma, 11 :453, 171. 4. Kilman, J. W., and Charneck, E.: Thoracic trauma in infancy and childhood. J. Trauma, 9:863, 1969. Division of Pediatric Surgery Johns Hopkins University School of Medicine Baltimore, Maryland 21205
Major Thoracic Trauma in Chi,ldren J. Alex Haller, Jr., M.D. * and Dennis W. Shermeta, M.D. **
Penetrating as well as blunt injuries to the chest occur frequently in adults, but in children penetrating injuries to the chest are rare. 1 Penetrating injuries usually result from fractured ribs or clavicles and not from external missiles.4 Blunt thoracic trauma is much more common in children and often requires immediate correction of functional deficits before anything is known of the mechanism of injury or of the child's previous physical condition.2 Hypoxia and hypotension allow little time for deliberation and consultation. On the other hand, hypotension from blood loss may begin insidiously and continue for long hours with excellent prognosis for complete recovery. Therefore, physicians and paramedical personnel who are responsible for the immediate care of an accident victim with a potential chest injury must be prepared to act according to some preconceived plan of evaluation and triage. In this discussion we propose to outline a course of action,including sequential evaluation, which we have developed in the management of multiple trauma, including blunt thoracic injuries, in the Children's Trauma Center of the Johns Hopkins Hospital. The concept that one person has primary responsibility for the evaluation of an injured child, preferably a pediatric surgeon, is so well established that it probably requires no further amplification. The initial evaluation and initiation of triage do not necessarily imply the presence of a well trained trauma physician, but it does entail the utilization of a nurse or physician substitute with experience in the management of major trauma. Triage and initial evaluation of a patient with blunt trauma may be conveniently divided into three categories which can be simplified to allow maximal utilization of paramedical personnel and junior house officers. These are arbitrary categories and are fluid in nature because the patient's response to treatment may necessitate change in status as the patient undergoes treatment and further evaluation. *Robert Garrett Professor of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland **Chief, Department of Pediatric Surgery, University of Maryland School of Medicine, Baltimore; Assistant Professor of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland Pediatric Clinics of North America- Vol, 22, No.2, May 1975
341
342
J. ALEX HALLER, JR., AND DENNIS W. SHERMETA
Figure 1.
Obstructed right main stem bronchus from aspirated premolar tooth.
Injuries Immediately Life-Threatening An example of a common injury in this category is upper airway obstruction from injury to the oral pharynx which results in aspiration of significant quantities of blood or foreign bodies such as teeth. CASE 1. A nine year old male was noted to have severe upper airway obstruction following trauma to the mouth and face. X-ray of the chest (Fig. 1) revealed a tooth in the right mainstem bronchus which was rapidly removed by endoscopy with immediate relief of respiratory distress.
Trauma to the trachea or bronchus may result in partial or complete rupture, which may result in rapidly increasing subcutaneous emphysema and progressive cyanosis. If initial attempts at endotracheal intubation are not effective, a tracheostomy may be life-saving. CASE 2. Chest x-ray of a four year old child (Fig. 2) who was resuscitated after being strangled by a station wagon back window. Marked mediastinal emphysema is demonstrated.
Intrathoracic hemorrhage may be detected by frequent monitoring of blood pressure and pulse and this potentially life-threatening complication can be quickly diagnosed and treated. Once a continuinghemotho-
MAJOR THORACIC TRAUMA IN CHILDREN
Figure 2.
343
Crushed trachea with marked mediastinal emphysema.
rax is recognized and prompt insertion of a thoracotomy tube effected, persistent drainage of blood is the indication for operative exploration. CASE 3. Depicts the initial chest x-ray (Fig. 3A) of a six year old girl struck by an automobile and admitted to the Trauma Center, semiconscious with obvious respiratory difficulty. Examination revealed slowly decreasing blood pressure and absent breath sounds on the right side. The chest x-ray showed pulmonary contusion and a hemopneumothorax with the mediastinum shifted to the left. A thoracostomy tube was inserted in the right ninth interspace with the immediate drainage of bright, red blood which persisted. Thoracotomy was carried out within a few hours and a laceration into the right lower lobe necessitated a lobectomy. Chest x-ray (Fig. 3B) shows immediate post-tube evacuation and 3C shows return of the initial status after six hours which prompted the decision for a thoracotomy. Figure 3D shows the status 12 days following right lower lobectomy. Most blunt .thoracic trauma is not associated with significant intrathoracic hemorrhage, but a fractured rib may cause major vascular injuries resulting in significant hemorrhage.
Major pulmonary and hilar vessels may be injured by fractured ribs or clavicles, as illustrated by the arteriogram (Fig. 4A) on an 11 year old boy who was run over by an automobile. He was brought to the Trauma Center with a cold, mottled, pulseless right arm and an obvious depressed right clavicular fracture. Elevation of the proximal third of the clavicle improved the appearance of the arm but without return of peripheral pulses. A suspected intrathoracic subclavian artery injury was
344
J.
ALEX HALLER
JR.,
AND DENNIS
W.
SHERMETA
Figure 3. A Traumatic hemopneumothorax and right pulmonary contusion. B Po tevacuation x-ray of hemopneumothorax. C Recurrent hemothorax in spite of thoraco tomy drainage. D Twel e days after right lower lobectomy for uncontrolled hemorrhage.
MAJOR THORACIC TRAUMA IN CHILDREN
345
evaluated by immediate arteriography. The arteriogram demonstrates stretching and spasm of the axillary artery without extravasation or intimal damage. Over the next six hours, the radial pulse returned and repeat arteriogram (Fig. 4B) several days later showed a normal arterial tree. This case illustrates the importance of utilizing arteriography in the evaluation of potential vascular injuries associated with blunt trauma, and also emphasizes the occasional presence of spasm associated with trauma rather than thrombosis or transection. In the management of patients with chest trauma and with potential blood loss and hypotension, we have been loathe to use the standard percutaneous subclavian catheter placement for the monitoring of central venous pressure. Because of the small size of the vessel and the incidence of iatrogenic pneumothorax, we have avoided using this technique to prevent increasing respiratory impairment in a child who already has blunt thoracic trauma. Instead, we have used a direct cutdown on the jugular vein preferring to thread a small Silastic catheter into the right atrium via this route. Since many of these children will, in addition, require large amounts of intravenous fluid in their resuscitation, the presence of a central venous pressure catheter can be a most important means of monitoring this replacement. In addition, such children should have a urethral catheter inserted into the urinary bladder to allow decompression of the bladder and evaluation of the urinary tract for possible associated injuries. Serious Injuries Not Immediately Life-Threatening This type of thoracic trauma is most commonly seen in multiple systems injuries in children. This group includes multiple rib fractures with pneumothorax or small hemopneumothorax. Closed thoracostomy and frequent evaluation of respiratory function including measurement of arterial p02 and pC02 are usually followed by rapid stabilization and recovery of children in a pediatric intensive care unit. The above findings may be associated with significant pulmonary contusion and are treated siInilarly but with the addition of intravenous antibiotic therapy to prevent secondary infection of the intrapulmonary hematoma; Multiple rib fractures with resultant flail chest have infrequently caused ventilatory difficulty in children. If, however, careful monitoring of blood gases indicates ineffectual gas exchange, we have not hesitated to provide positive pressure ventilation through an endotracheal tube for several days. A tracheostomy tube has rarely been necessary, but when indicated, the new plastic tracheostomy tubes have been quite satisfactory with a very low incidence of tracheal stenosis or other local complications. Traumatic asphyxia is also included in this category. Traumatic asphyxia apparently results from sudden compression of the thoracic cage, while the glottis is closed.3 This sudden increase in pressure drives the venous blood into the capillaries resulting in extravasation and hemorrhages in brain tissue may result in loss of consciousness, convulsions, and occasionally other significant neurologic sequelae. As soon as the etiology of the chest compression is relieved, there is a slow but con-
346
J.
ALEX HALLER JR.
A D DE
IS
W.
SHERMETA
Figure 4. A, Percutaneou femoral aortogram for e aluation of ab ent pulse in right arm after cru h injury to right upper che t. ote right cIa icular fracture. B Repeat arteriogram three da after trauma howing complete re olution of a cular pa m .
tinuous subsidence of the petechial hemorrhages with complete resolution common in five to seven days. Injuries to Thoracic Cage and Isolated Pulmonary Contusions This third type of injury is illustrated by the chest x-ray of a nine year old boy who was struck by a baseball in the left anterior chest (Fig. 5A). A large pulmonary contusion strikingly localized is seen with-
Fi ure 5. A, Localized radio den ity in left mid-lung field following ba eball injury of che t. B, Same child two day later howing complete re olution of pulmonary contu ion.
r
MAJOR THORACIC TRAUMA IN CHILDREN
347
out significant impairment of respiratory function or alteration in blood gases. Repeat chest x-ray two days later showed complete resolution (Fig.5B). Our experience with major blunt trauma in children has shown that significant thoracic injuries are frequently a component of multisysterns injuries; and therefore, a proper sequence must be followed in the management of the whole spectrum of multi-organ injuries. Whatever therapy is rendered, it must be aimed toward maintaining satisfactory ventilation and adequate airway and optimal tissue perfusion throughout the course of evaluation and resuscitation. This may require the insertion of a thoracostomy tube prior to the induction of general anesthesia for evacuation of an associated subdural hematoma or an intra-abdominal injury. This type of preventive insertion of a chest tube must be done without hesitation, for if a tension pneumothorax occurs intraoperatively under anesthesia, it may be undetected or discovered too late to provide adequate ventilation. Total evaluation of the child with major blunt trauma is a diagnostic challenge requiring the greatest experience and skill in judgment. A well organized system of evaluation and resuscitation, including the use of monitoring techniques, is necessary for first class treatment of children with major blunt trauma
REFERENCES 1. Bellinger, S. B.: Penetrating chest injuries in children. Ann. Thorac. Surg., 14:635, 1972. 2. Cohn, R.: Non-penetrating wounds of the lungs and bronchi. Surg. Clin. N. Am., 52:585, 19672. 3. Haller, J. A., and Donahoo, J. S.: Traumatic asphyxia in children. J. Trauma, 11 :453, 171. 4. Kilman, J. W., and Charneck, E.: Thoracic trauma in infancy and childhood. J. Trauma, 9:863, 1969. Division of Pediatric Surgery Johns Hopkins University School of Medicine Baltimore, Maryland 21205
