Pediatric Chest Trauma Catherine J Goodhue, MN, CPNP ... · Tension Pneumothorax •Kids at greater risk •Beck’s triad ... LK. Mortality after emergency department thoracotomy

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39th National Conference on Pediatric Health Care

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March 19-22, 2018 CHICAGO

Pediatric Chest Trauma

Catherine J Goodhue, MN, CPNPDivision of Pediatric Surgery/Trauma Program

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Disclosures

• No Disclosures

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Learning Objectives

After attending this lecture, the participant will be able to:

• Discuss common mechanisms of injury in pediatric thoracic trauma and likely subsequent injuries

• Review common traumatic injuries and diagnosis of thoracic trauma

• Describe interventions and treatment of thoracic trauma

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PEDIATRIC TRAUMA

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Case Study #1 ‐ PJ

• 11 year old male MVC crash

– Front seat passenger

• ?LOC at scene/+death on scene

• Vitals

– HR 116 beats/min

– RR 24 breaths/min

– BP 110/70

• 3 minute ETA

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WHAT IS THE INCIDENCE OF PEDIATRIC CHEST TRAUMA?

a. 5%

b. 10%

c. 15%

d. 20%

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WHAT PERCENTAGE OF PEDIATRIC CHEST TRAUMA IS BLUNT?

a. 40‐50%

b. 51‐60%

c. 61‐70%

d. 71‐80%

e. 81‐90%

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Mechanisms ‐ Blunt

• Motor vehicle crashes

• Auto vs pedestrian

• ATV accidents

• Falls

• Sports injuries

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What’s in the Chest?

• Bones– Rib fractures

– Spine fractures

• Things that Bleed– Heart

– Major vessels

– Medium/small vessels

• Things that Leak– Major airways

– Esophagus

– Minor airways

• Diaphragm and Below– Liver/spleen

– Hollow viscera

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Pediatric Chest Anatomy/Physiology

–More compliant chest wall

– Less muscle mass

–Mobile mediastinum

– Hypoxia develops faster

– Babies obligate nose breathers

– Kids abdominal breathers

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WHAT RADIOLOGIC STUDY(IES) WOULD YOU ORDER TO RULE OUT CHEST TRAUMA?

a. No radiological studies are necessary

b. Chest CT scan

c. Chest x‐ray

d. Spiral chest CT scan

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WHAT IS YOUR DIAGNOSIS?

a. Normal chest x‐ray

b. Pulmonary contusion

c. Hemothorax

d. Pneumothorax

e. Rib fractures

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Pneumothorax

• Physical findings may include:

– Tachycardia

– Hypoxia

– Diminished breath sounds

– Crepitus

– Hyperresonance

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Tension Pneumothorax

• Kids at greater risk

• Beck’s triad

– Hypotension

– Distended neck veins

– Distant heart sounds

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Chest Tube Maintenance

• Daily chest x‐ray

• Do not milk

• Removal at bedside

• No flying or scuba for at least 2 weeks

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Other Diagnostic Studies

• Labs

• Type and screen/cross

• Imaging studies

– CXR

– FAST?

• EKG?

• ?Echocardiogram

• ?Bronchoscopy

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Secondary Survey

• Thorough head to toe physical exam

– Don’t forget the back

– Inspect

– Palpate

– Percuss

– Auscultate

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Disposition Case Study #1 PJ

• Admitted

• Close monitoring

• Tertiary survey

• Trauma f/u clinic

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Case Study #2 ‐ CJ

• 14 year old male ATV crash

• Vitals



– BP 120/70

• 5 minute ETA

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Secondary Survey ‐ Case Study #2 ‐ CJ

• 14 year old male ATV crash

• Physical findings

– Left suprachondylar fracture

– Road rash on hands and face

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a. Rib fractures

b. Normal chest x‐ray

c. Pulmonary contusion

d. Cardiac contusion

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Pulmonary Contusions

• Pathophysiology

– Alveolar‐capillary wall damage

• Treatment

– Avoid overhydration

–Monitoring

– Adequate gas exchange

– Good PULMONARY TOILET

– Pain control

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Disposition Case Study #2 ‐ CJ

• Discharged home after 4 days

• Long arm cast

• Ortho f/u

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Case Study #3 ‐ JT

• 5 year old female ATV crash

• Vitals



– BP 104/64

• 3 minute ETA

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Secondary Survey #3 ‐ JT

• 5 year old female ATV crash

• Physical exam

– Right side facial edema

– Right wrist deformity

– Right rib pain/erythema

– RUQ abdominal pain

– Abrasion RUQ

– Pulse now 140 beats/minute

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Next Step #3 ‐ JT

WHAT RADIOLOGIC STUDY IS MOST APPROPRIATE?

a. Chest CT scan

b. Abdominal CT

c. Spiral chest CT scan

d. No further radiologic tests

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Abdominal CT findings

• Grade I liver laceration

• Rib fracture

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Rib fractures in pediatrics

• Significant amount of force

• Look for underlying organ damage

• 1st rib fractures in kids

• Mortality rate

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Hospital Course #3 ‐ JT

• Close monitoring

– Pain control

– Pulmonary toilet

• Casting right wrist

• CT face – negative

• Discharged home

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Case Study #4 ‐ MZ

• 15 year old male

• Healthy with no health issues

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WHAT IS YOUR INITIAL RESPONSE?

a. Run to the teen and assess CAB

b. Let the coach check him out

c. Let his parent take him to the hospital

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WHAT IS YOUR INITIAL DIAGNOSIS?

a. Heat stroke

b. Commotio cordis

c. Prolonged QT syndrome

d. Cardiac tamponade

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WHAT IS YOUR NEXT STEP AFTER STARTING CPR?

a. Asking parents to take him to hospital

b. Telling someone to get the AED

c. You’ve done all you can

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Disposition #4 ‐ MZ

• Shock x 2

• Paramedics arrived

• Hospitalized

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Case Study #5 ‐ MC

• 3 month old female presents with wheezing

• Vitals



– BP 124/70

• Normal birth history

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WHAT DO YOU DIAGNOSE ON THE CHEST X‐RAY?

a. Cardiomegaly

b. Infiltrate

c. Rib fractures

d. No findings

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WHAT IS YOUR NEXT STEP?

a. Do nothing, the chest x‐ray was normal

b. Call child’s pediatrician for more history

c. Call local police department

d. Call Social Work

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WHAT OTHER TESTS/CONSULTS, IF ANY, WOULD YOU OBTAIN?

a. None

b. Skeletal survey and Ophthalmology consult; AST/ALT

c. Have family follow up with Pediatrician

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Results of Ophtho consult and Skeletal Survey

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Disposition #5 ‐ MC

• Baby hospitalized

• Eventually discharged to foster care

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Mechanisms ‐ Penetrating

• GSW

• Stabbing

• Impalement

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Penetrating Chest Trauma

• THE BOX – “high‐risk” for cardiac injury

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Case Study #6 ‐ AB

• 3 year old female

• Shot by sibling accidently with BB gun

• Vital signs

– Heart rate 144 beats/minute

– Respirations 32/minute

– BP 108/62

• ETA 2 minutes

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– Spine fractures


– Major vessels



– Esophagus

– Minor airways


– Hollow viscera

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WHAT RADIOLOGIC STUDY(IES) WOULD YOU ORDER TO RULE OUT CHEST TRAUMA?

a. No radiological studies are necessary

b. Chest CT scan

c. Chest x‐ray

d. Spiral chest CT scan

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a. Take to OR for removal

b. Admit for observation

c. Discharge home from ED

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Disposition #6 ‐ AB

• Admitted for 24 hour observation

• Injury prevention consult

• Discharged home

• Trauma Clinic f/u

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Case Study #7 ‐ ZZ

• 15 year old male

• Drive by shooting

• Vital signs

– Pulse 110 beats/minute

– Respirations 18/minute

– BP 110/70

• 1 minute ETA

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– Spine fractures


– Major vessels



– Esophagus

– Minor airways


– Hollow viscera

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a. Pneumothorax

b. Cardiomegaly

c. Hemothorax

d. Normal chest x‐ray

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a. Get a chest CT scan

b. Insert chest tube

c. Nothing as chest x‐ray normal

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Chest Tubes – To operate or not?

• >20 cc/kg blood from first tube

• Inability to expand lung with chest tube

• Persistent air leak after several days

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Disposition #7 ‐ ZZ

• Admitted under alias

• Resolution of hemothorax

• Discharged home

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ED Thoracotomy

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Cardiac tamponade

• Beck’s triad

– Hypotension

– JVD

–Muffled heart sounds

• Pulsus paradoxus

• OR IMMEDIATELY

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References

• Armstrong LB, Mooney DP. Pneumatoceles in pediatric blunt trauma: common and benign. 2017. Journal of Pediatric Surgery.

• Council on Injury, Violence, and Poison Prevention Executive Committee of the American Academy of Pediatrics. Firearm‐related injuries affecting the pediatric population. 2012. Pediatrics; 130; e1416.

• Farrokhian AR. Commotio cordis and contusio cordis: possible causes of trauma‐related cardiac death. 2016. Archives of Trauma Research; 5(4):e41482.

• Flagel BT, Luchette FA, Reed R, Esposito TJ, Davis KA, Santaniello JM, Gamelli RL. Half‐a‐dozen ribs: the breakpoint for mortality. 2005. Surgery; 138:717‐725.

• Flynn‐O’Brien KT, Steward BT, Fallat ME, Maier RV, Arbabi S, Rivara FP, McIntyre LK. Mortality after emergency department thoracotomy for pediatric blunt trauma: analysis of the National Trauma Data Bank 2007‐2012. 2016. Journal of Pediatric Surgery; 51: 163‐167.

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References

• Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM. Rib fractures in children: a marker of severe trauma. 1990. Journal of Trauma; 30:695‐700.

• Golden J, Isani M, Bowling J, Zagory J, Goodhue CJ, Burke RV, Upperman JS, Gayer CP. Limiting chest computed tomography in the evaluation of pediatric thoracic trauma. 2016. Journal of Trauma and Acute Care Surgery; 81: 271‐277.

• Hamilton NA, Bucher BT, Keller MS. The significance of first rib fractures in children. 2011. Journal of Pediatric Surgery; 46:169‐172.

• Hamrick MC, Duhn RD, Carney DE, Boswell WC, Ochsner MG. Pulmonary contusion in the pediatric population. 2010. The American Surgeon; 76:7, 721‐724.

• Holmes JF, Sokolove PE, Brant WE, Kuppermann N. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. 2002. Annals of Emergency Medicine; 39:5; 492‐499.

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References

• Holscher CM, Faulk LW, Moore EE, Burlew CC, Moore HB, Stewart CL, PieracciFM, Barnett CC, Bensard DD. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. 2013. Journal of Surgical Research; 184: 352‐357.

• Jhunjhunwala R, Mina MJ, Roger EI, Dente CJ, Heninger M, Carr JS, Dougherty SD, Gelbard RB, Nicholas JM, Wyrzykowski AD, Feliciano DV, Morse BC. Reassessing the cardiac box: a comprehensive evaluation of the relationship between thoracic gunshot wounds and cardiac injury. 2017. Journal of Trauma and Acute Care Surgery; 83:3; 349‐355.

• Kaptein YE, Talving P, Konstantinidis A, Lam L, Inaba K, Plurad D, Demetriades D. Epidemiology of pediatric cardiac injuries: a National Trauma Data Bank analysis. 2011. Journal of Pediatric Surgery; 46: 1564‐1571.

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References

• Kessel B, Dagan J, Swaid F, Ashkenzi I, Olsha O, Peleg K, Givon A, Israel Trauma Group, Alfici R. Rib fractures: comparison of associated injuries between pediatric and adult population. 2014. The American Journal of Surgery; 208: 831‐834.

• McNamara C, Mironova I, Lehman E, Olympia RP. Predictors of intrathoracic injury after blunt torso trauma in children presenting to an emergency department as trauma activations. 2017. Journal of Emergency Medicine; 52:6; 793‐800.

• Moore HB, Moore EE, Bensard DD. Pediatric emergency thoracotomy: a 40‐year review. 2016. Journal of Pediatric Surgery; 51: 315‐318.

• Muzzy AC, Butler AK. Managing chest tubes: air leaks and unplanned tube removal. 2015. American Nurse Today; 10: 10‐13.

• Pearson EG, Fitzgerald CA, Santore MT. Pediatric thoracic trauma: current trends. 2017. Seminars in Pediatric Surgery; 26:36‐42.

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References

• Platz JJ, Fabricant L, Norotsky M. Thoracic trauma: injuries, evaluation, and treatment. 2017. Surgery Clinics in North America; 97: 783‐799.

• Stephens CQ, Boulos MC, Connelly CR, Gee A, Jafri M, Krishnaswami. Limiting thoracic CT: a rule for use during initial pediatric trauma evaluation. 2017. Journal of Pediatric Surgery.

• Weerdenburg KD, Wales PW, Stephens D, Beno S, Gantz J, Alsop J, Schuh S. Predicting thoracic injury in children with multitrauma. 2017. Pediatric Emergency Care; 00; 1‐5.

• Yanchar NL, Woo K, Brennan M, Palmer CS, Ee, MZS, Sweeney B, Crameri J. Chest x‐ray as a screening tool for blunt thoracic trauma in children. 2013. Journal of Trauma and Acute Care Surgery. 375: 613‐619.

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Pediatric Chest Trauma Catherine J Goodhue, MN, CPNP ... · Tension Pneumothorax •Kids at greater risk •Beck’s triad ... LK. Mortality after emergency department thoracotomy