Topic №7: Childhood trauma. Abdominal trauma. Thoracic Trauma. Esophageal injury
Introduction
Trauma is the leading cause of disability, death, and hospitalisation among children and adolescents globally. It constitutes an enormous financial burden on society in particular and governments in general.
The impact of injury in developing nations has not been as extensively studied as in industrialised countries, and therefore often is not fully appreciated. Traditionally, infectious diseases and malnutrition have predominated as causes of morbidity and mortality in developing countries. All the same, injury is a major health problem among children of all ages worldwide.
For most parts of the African subregion, there are no trauma registries, and as such, it is difficult to know how much trauma contributes to injuries and death. Accurate data on the extent and nature of injuries are required to formulate effective policies targeted at reducing the burden of injury and in particular to compare the contribution to morbidity and mortality due to injuries with that due to infectious diseases and malnutrition. Most of the studies on injuries in the subregion are hospital-based; given the limited access to hospital care and emergency transport in low-income countries, these studies are unlikely to be truly representative of what is happening in the communities.
By the estimates of the World Health Organization (WHO) and the World Bank, injury is likely to account for 20% of all disability-adjusted life year (DALY) losses for the world’s population by 2020. Road traffic injuries alone are the third leading cause of DALY losses. In spite of this, very little attention is paid to injury as a major health problem globally, particularly in the developing world.
The care of trauma patients is a continuous process and involves the initial first aid, the in-hospital care for the acute phase, and finally rehabilitation. For this to be successful, a trauma system must be put in place involving hospitals, trained personnel, and public agencies such as the ambulance services and the Red Cross, among others. Such a trauma system will require communication capabilities to be able to triage and rapidly transport injured children from the field of injury to a suitable facility for immediate treatment and rehabilitation. Frankly, the focus in the African subregion should be on injury prevention because treating injuries is very expensive and the costs of injuries to society are enormous.
Epidemiology of Injury in Children
Knowledge of the epidemiology of injury will help with prevention methods. Epidemiology is the study of the factors determining and influencing the frequency and distribution of disease, injury, and other health-related events, as well as their causes in a defined human population.
Epidemiology of injury involves the collection of data concerning the time, the place, the mechanism, and the victim of injury. The purpose of studying injury and its causes is to establish programmes to prevent and control its development and spread. Injury is known to be a leading threat to the health of children in Africa, with unintentional injuries being the leading cause of morbidity and mortality.
Injuries are subdivided into life threatening and non–life threatening. Life-threatening injuries may be intentional or unintentional. Such injuries occur when a child is exposed to mechanical, electrical, or thermal energy. Childhood injuries can be penetrating or nonpenetrating, with blunt injuries predominating; but many penetrating injuries can be disturbing and life threatening.
Injury sustained by an 8-year-old boy who climbed a carpenter’s
work table to pluck mangoes from a mango tree. He fell off the table, and
in the process fractured his radius and ulna. He was treated by a traditional
bonesetter who applied herbal concoctions. This is the end result of his fall.
Treatment in hospital was by above-elbow amputation of the right upper limb.
He survived the ordeal, but he will be permanently disabled.
Injuries should not be considered as random events or accidents. They have an association with many predictable factors, such as age, sex, geographic location, and socioeconomic status. Risk for serious injury is highly age-related. There are also developmental-related vulnerabilities. Young infants are at higher risk of inflicted trauma due to their small size and inability to protect themselves. Risks forteenagers are higher as a result of increased exposure to hazards and risk-taking behaviours. In other words, the range of causes of injury and the character of the injuries seen in children vary with age. For example,transport-related injuries are common in all age groups but are foundto be more common in teenagers and adolescents, with resultant high morbidity and mortality rates in these age groups. Also, burn injuries are more rampant in children younger than 4 years of age than in older children. In developing countries, falls are usually the most common cause of injury seen in hospitals, affecting the age group of 5–9 years more than other age groups.
Overall, injury rates are higher in socioeconomically less-endowed communities than in more affluent societies. In addition, boys are more likely than girls to be harmed by unintentional injuries. Various research studies have demonstrated this fact and have concluded that male sex is a risk for all types of injury death, with the ratio of male deaths to female deaths varying by injury mechanism.
Unintentional Injuries
The mechanisms of unintentional injuries in children include transportation accidents, falls, burns, insect or animal stings and bites, agricultural injuries, drownings and submersions, poisonings, suffocations, and gunshot wounds.
From American College of Surgeons Committee on Trauma: Advanced Trauma Life Support for Doctors Student Manual, 8th ed. Chicago, American College of Surgeons, 2008.
From Cooper A, Barlow B, DiScala C, et al: Mortality and truncal injury: The pediatric perspective. J Pediatric Surg 29:33-38, 1994.
Figure : Algorithm for the initial assessment and resuscitation of a paediatric trauma patient.
Table Glasgow Coma Scale revised for use in pediatric population
Abdominal Trauma
Introduction
Abdominal trauma is common in children, accounting for about 5% of admissions to major paediatric centres.1–5 Most injuries are blunt in nature, but the incidence of penetrating trauma injuries is increasing. Although most blunt trauma injuries result from traffic injuries, falls (frequently off fruit-bearing trees) are particularly important in sub- Saharan Africa and other developing countries.1,3,6 Firearms, bicycles, sports, and injuries inflicted as a result of child abuse are becoming increasingly noticeable in developing countries.7–8
A number of factors make children particularly vulnerable to abdominal injury. The relatively thin abdominal wall and lower rib cage in children means that the liver, kidney, and pancreas lie in close proximity to the anterior abdominal wall and are prone to injury even if the cause of trauma is trivial. Besides, the liver and kidneys, which are normally protected by the rib cage in adults, lie relatively lower in the abdomen of the child, making them vulnerable to injury. The liver also occupies a proportionately larger percentage of the child’s abdomen, further exposing it to increased risk of injury. Abdominal trauma is frequently associated with other extraabdominal injuries, which should not be overlooked. A distended stomach and full bladder may interfere with the evaluation of the injured child, and may need to be promptly emptied.
Blunt Abdominal Trauma
Blunt injury accounts for up to 86% of abdominal trauma.3 In children, blunt abdominal trauma produces a spectrum of injuries that may pose diagnostic and treatment challenges in the African setting, with its limited diagnostic facilities.4 Special attention should be directed at handlebar injuries (which cause focused liver, pancreatic, duodenal, and jejunal injuries); lap-belt injuries (which produce a triad of abdominal abrasion, intestinal perforation, and intestinal laceration), and child abuse (in which the face and head may be involved). Bowel injuries may also cause significant morbidity due to a delay in diagnosis.6
Clinical Evaluation
After the initial evaluation, resuscitation, and stabilisation, the child with blunt abdominal trauma is carefully and thoroughly evaluated. An additional history is obtained, paying particular attention to vomiting, haematemesis, or rectal bleeding, which may indicate rectal or proximal intestinal injury. A history of loss of consciousness should be sought, as this may indicate head injury.
The presence of pallor, abdominal distention, and pain on physical examination may be a pointer to intraabdominal bleeding. The pulse rate should be carefully monitored, as it is a more sensitive indicator than blood pressure of haemodynamic status in children. Careful examination of the abdomen is performed, with particular attention to abrasions, bruises, distention, and tenderness. Note that peritoneal signs are particularly difficult to discern in a child with lower rib fractures, contusion or abrasions of the abdominal wall, pelvic fractures, and distended bladder. Abdominal examination may be unreliable in patients with head injury or depressed sensorium, so repeated examination or other diagnostic tests are ofteecessary in such patients. Decompression of the stomach with a nasogastric tube and the passage of a urethral catheter (except if there is blood at the external meatus or a floating prostrate) may be helpful when examining children with blunt abdominal trauma. Rectal examination should be done to look for perianal soilage with blood, tenderness, floating prostate, or a palpable rent in the rectum. The examining finger should be inspected for blood stain.
The chest, central nervous system and musculoskeletal system should be examined to exclude injury in these systems.
Investigations
Relevant investigations of a child with abdominal trauma would include the techniques discussed in the following subsections.
Abdominal Ultrasonography
Focused abdominal sonography for trauma (FAST) is directed at identifying intraperitoneal or pericardial fluid, which may result due to solid organ injuries (spleen, liver, kidneys, heart). When available, it could be used as a screening tool in the immediate assessment of blunt abdominal trauma. The FAST examination evaluates four areas:
1. right upper quadrant including the hepatorenal fossa;
2. left upper quadrant including the perisplenic region;
3. right and left paracolic gutters and the pelvis; and
4. intercostal or subdiaphragmatic view of the heart.
Note that the FAST examination does not always identify injured solid organs, and its sensitivity depends on the skills of the operator.
Diagnostic Peritoneal Lavage
The aim of diagnostic peritoneal lavage (DPL) is to detect bleeding or leakage of intestinal contents or pancreatic juice into the free peritoneal cavity. This investigation is used for the evaluation of a traumatised child who is unstable. It may require urgent laparotomy for deteriorating neurologic status or when the source of blood loss or clinical findings are in doubt. DPL may be very helpful in resource-poor settings, where advanced imaging modalities are not available, to select patients who need operative intervention.
DPL is performed by placing a catheter under direct vision into the peritoneal cavity. In infants with no previous surgery, a plastic-sheathed needle is passed obliquely into the lower quadrant. In older children without previous surgery, the catheter may be passed by using the
Seldinger technique. A positive result is obtained when blood, intestinal contents (bile-stained fluid), or free peritoneal air is encountered. If free fluid is obtained, 15 ml/kg body weight of Ringer’s lactate or normal saline is introduced into the abdominal cavity and the effluent is analysed for red blood cells (RBC) (> 50,000/ml), white blood cells (WBC) (>500/ml), and the presence of intestinal contents and amylase. In children, the presence of blood alone at DPL is not necessarily an indication for operation because it could be due to solid organ injuries that can be managed nonoperatively.
Erect Plain Abdominal Radiograph
An erect plain abdominal radiograph should include the chest and pelvis. The findings should be correlated with clinical findings to avoid unnecessary laparotomy. Findings may include free peritoneal air (Figure 29.1) in intestinal rupture, medially displaced gastric or colonic gas shadow in splenic rupture, or generalised ground-glass appearance of massive intraperitoneal or retroperitoneal haemorrhage. Rib and pelvic fractures may be seen.
Figure 29.1: Free air in the peritoneal cavity due to intestinal perforation from blunt trauma.
Computed Tomography
The contrast-enhanced (intravenous (IV) or enteral) computed tomography (CT) scan is probably the most useful imaging modality to identify and characterise solid and hollow visceral injury. It provides clear and accurate imaging of the intraabdominal organs, including intestinal perforation and injuries to retroperitoneal structures. The CT scan may show a contrast blush—a well-circumscribed area of contrast extravasation that is hyperdense with respect to the surrounding parenchyma (Figure 29.2). The contrast blush is a specific marker of active bleeding associated with a higher rate of operative intervention in children.
Source: Courtesy of Manuel Meza, MD, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Figure 29.2: Contrast blush seen on CT scan in a patient with grade 4 splenic laceration (arrow), indicating active bleeding. Note the haemoperitoneum over the liver.
Notwithstanding whether a contrast blush is present, however, the decision to operate should be made on the basis of clinical response to resuscitation; clinically stable patients with a contrast blush can be successfully treated nonoperatively.9 Although a CT scan is widely accepted and gives accurate results with few false-positive and false-negative interpretations, it may not be readily available in some centres in Africa.
Exploratory Laparoscopy and Laparotomy
When available, laparoscopy can be valuable in the diagnostic evaluation of patients who are haemodynamically stable but there is a strong suspicion of intraabdominal organ injury.
Laparotomy may be needed for definitive diagnosis and treatment. It is indicated in the patient who responds poorly to adequate resuscitation efforts consisting of greater than 40 ml/kg of crystalloids or one-half the child’s blood volume within the first 24 hours after injury. Blood should be grouped, cross-matched, and stored for a transfusion, wheecessary.
To summarise, the surgeon in Africa, and indeed elsewhere, must be proficient in the clinical evaluation of the traumatised child with suspected intraabdominal injuries, even with the availability of advanced imaging techniques.10 The value of clinical examination was demonstrated in a study by Chirdan et al. showing a drastic reduction in the rate of laparotomy without compromising outcome in resource-poor settings when a simple management algorithm is used. The algorithm includes clinical examination and simple radiology and laboratory tests.4
Trauma is the leading cause of death and disability in the pediatric population. While head injuries are the most likely to be lethal, the abdomen is the most common sight of occult injury that results in death. The management of abdominal injuries has evolved in recent decades as non-operative strategies have been met with increasing success.
The initial approach to a child with trauma should begin with the standard American Trauma Life Support teachings, namely assessing airway, breathing and circulation. It is during the secondary survey that the abdomen is evaluated. Concern for an intra-abdominal injury might arise as a result of the clinical history, as part of the physical examination performed during the secondary survey, or both. Hemodynamically unstable patients with concern for an intra-abdominal source for hemorrhage are best managed in the operating room, however this represents a small proportion of the abdominal trauma population. The physiologic condition of most children undergoing evaluation allows for a thoughtful, but timely, evaluation.
There are anatomic differences between children and adults that make intra-abdominal injuries more likely. The intra-abdominal organs, especially the liver and spleen, are protected in the adult by the thoracic cage, but are proportionately larger in the child and can extend beyond the costal margin, exposing them to traumatic external forces. Because of increased compliance of the ribs, more energy is transmitted to the underlying structures and less diffused by fracture. Also, in the younger children, the abdominal wall musculature is less well developed and thus affords relatively little protection to the underlying internal organs.
There are several physical findings that should increase your index of suspicion for an abdominal injury. Notably, bruising of the abdomen (classic seatbelt sign or more subtle bruising of the abdominal wall) greatly increases the risk of intra-abdominal injury in the setting of a motor vehicle crash related injury. As such, advanced imaging should be considered for these patients. Periumbilical ecchymosis (Cullen’s sign) or flank ecchymosis (Grey-Turner’s sign) should raise concern for intra-abdominal or retroperitoneal injury and the need for advanced imaging. Likewise, fractures of the lower ribs are indicative of significant force and should also raise concern for intra-abdominal injury.
After completion of the primary and secondary survey, a plan of care should be formulated for both global concerns as well as the abdomen. The need for laboratory and imaging studies should be considered. The routine use of laboratory studies in the evaluation of the patient with abdominal trauma remains controversial. Most studies have demonstrated limited utility to the use of laboratory studies such as liver function studies or amylase and lipase for routine screening. As a screening tool, they may better be reserved for selected cases, such as possible child abuse, in which the mechanism is uncertain and thus the level of suspicion for intra-abdominal injury less clear. In patients with real concerns for intraabdominal injury, a CBC (a normal hemoglobin level may be falsely reassuring in the acute setting but important to follow over time) and serum electrolytes should be obtained. Urinalysis (or dip stick assessment for blood) should be performed as well. A specimen for type and crossmatch should also be strongly considered as guided by the clinical scenario. Other laboratory studies, (PT/PTT, Ca, PO4) are utilized selectively but infrequently.
Intravenous access can be challenging in the pediatric patient but is of utmost importance. Ideally, two age-appropriate large-bore intravenous catheters should be placed in any patient with concerns for abdominal trauma. At least one of these catheters should be placed above the level of the diaphragm in case a major venous injury exists in the abdomen. In the unstable patient, limited attempts should be made at peripheral catheters before central venous access is obtained. Intraosseus lines should also be considered in young children (up to age 6 years, perhaps older) as a reliable initial access site. These lines can be used for volume and blood infusions as well as for medication administration. However, these lines are unstable and should be replaced with more durable sites as soon as feasible.
Diagnosis
Imaging studies are commonly employed in the evaluation of the child with a suspected intra-abdominal injury. Plain films of the abdomen are typically of limited value but might demonstrate free air if a bowel perforation has occurred.
Figure . A, Bowel wall thickening and enhancement is seen on a CT scan of a patient with documented traumatic small bowel perforation. B, Free intra-loop fluid and bowel wall thickening are found on this CT scan in a patient with a small bowel perforation from a lap belt injury.
Pelvic films may be useful in patients with a possible fracture, however, most such patients should be considered for computed tomography of the abdomen and pelvis, in which case the plain films are superfluous. The mainstay of evaluation of the pediatric abdomen for trauma is the CT scan, however the need for CT should always be questioned and the study obtained only if clinically indicated. The CT scan should include the abdomen and pelvis and should be performed with intravenous contrast enhancement. The ability to characterize solid organ injuries is greatly diminished without IV contrast.
Figure. CT scans are highly accurate in demonstrating solid organ injuries. A, Hemoperitoneum with a liver laceration (arrow) and a shattered spleen is seen. B, Hemoperitoneum and a left renal laceration (arrow) is shown.
The utility of oral contrast in the trauma setting is still of some debate. We prefer to use oral contrast when safe (if a nasogastric tube is in place or if the subject is willing and able to drink) as it provides greater detail in evaluating the proximal bowel. Forcing oral contrast or placing an NG tube for the sole purpose of contrast administration should be discouraged. In the adult trauma population, ultrasound of the abdomen (FAST exam) has been widely embraced and utilized. The utility of FAST in the pediatric population is less clear. As most of our treatment algorithms are predicated on the grade of organ injury (rather than the presence or absence of free-fluid in the abdomen), FAST has been used only sparingly. However, FAST might be of value in determining if there is an evolving intra-abdominal process in hemodynamically unstable inpatients or in patients for whom transport to a CT scanner is deemed hazardous. Clinical deterioration of a trauma patient already in the operating room for other procedures (craniotomy) might also be an indication for FAST. In today’s armamentarium of noninvasive studies, diagnostic peritoneal lavage is currently of limited value. DPL can be an alternative in selected clinical scenarios if FAST is unavailable.
Penetrating Injuries
Penetrating injuries account for 5–10% of trauma admissions in most major pediatric centers. In most cases, penetrating injuries to the abdomen generally warrant laparotomy after full completion of the ATLS-based evaluation and resuscitation. Determination of the trajectory is key in management of this population. Many patients with intra-abdominal injuries will have remote entrance wounds (thigh, buttock, or chest), and it is important to remember that 15% of children with an intra-abdominal injury will also have injuries to other body regions. Diagnostic imaging plays a vital role in trajectory determination and is also important in accounting for all projectiles: what appear to be entrance and exit wounds could in fact represent two entrance wounds.
Physical examination is, of course, necessary and, in conjunction with imaging, one can estimate the likelihood of internal injuries. Hemodynamic instability or clear evidence of peritonitis mandates urgent laparotomy, typically through a midline abdominal incision. In selected patients, a nonoperative strategy might be reasonable. Such an approach should only be considered in the hemodynamically stable patient with a trajectory that does not suggest major vascular injury or hollow visceral injury. The patient with a simple solid organ injury from a low-energy missile (stab wound) that is not actively bleeding can potentially be observed, but those having sustained a high-energy mechanism (gunshot wound) or in whom the trajectory is not clear need to be promptly explored. Though CT has been advocated for determining trajectory, clinical deterioration or evidence of peritonitis is an absolute indication for surgical exploration.
Laparoscopy can be used in patients whose extent of injury is unclear, such as when local wound exploration suggests minimal violation of the fascia or when CT findings suggests that the missile’s trajectory was in proximity to vital structures. Indications for repair of penetrating organ injuries and conversion to laparotomy are the same in children as in adults. It is generally prudent to sterilely prepare the patient widely to include the chest and both lower extremities in case the laparotomy incisioeeds to be extended to include a thoracotomy or if autologous vein graft material is needed for vascular reconstruction. Available surgical techniques include: suture repair or partial resection of injured structures, control of active bleeding, judicious placement of closed suction drains, and, in the rare case of severe devitalizing injuries of the bowel or rectum with extensive peritoneal soilage, creation of a protective ileostomy or colostomy. In the stable patient, partial splenectomy is preferred over total splenectomy and drainage of a penetrating pancreatic injury is usually adequate and avoids prolonged and complicated repairs. In the unstable child with uncontrolled hemorrhage, salvage procedures that include packing the abdomen, temporary fascial closure, a period of resuscitation in the ICU and return to the operating room in 12–24 h for definitive repair are also acceptable and certainly preferred over heroic measures that ultimately fail.
Solid Organ Injuries
Over the last several decades, the management of solid organ injuries has evolved to a largely non-operative approach. Guided by early studies demonstrating the safety and efficac of this approach for the management of splenic injuries, this strategy has subsequently been successfully applied to liver and kidney injuries as well. Contemporary studies have demonstrated success rates in excess of 90% for non-operative management of solid organ injuries, even for severe injuries. Solid organ injuries are graded using the Organ Injury Scaling system devised by the American Association for the Surgery of Trauma (Table 18.1). We use the injury severity score to guide our treatment protocols but not as an indication for surgical intervention.
Although the patterns for peak time to operative intervention vary for the specific organs injured and injury severity, most children with a solid organ injury requiring surgery will need operative intervention within 24 h of admission. Children who fail a non-operative strategy due to ongoing hemorrhage, do so in predictable patterns. The “nonresponder” does not improve with the initial infusion of intravenous fluid (two 20 mL/kg boluses of warmed normal saline or lactated ringer’s solution), needs early consideration for transfusion of blood products, and will frequently require operative intervention. “Transient responders” improve with initial fluid challenges but later require additional fluid or blood due to a physiologic deterioration and should be considered candidates for angioembolization for control of ongoing hemorrhage. The majority of children are “responders.” That is, initial volume resuscitation, when necessary, adequately restores any existing physiologic abnormalities and maintenance fluid administration alone is utilized subsequently.
Table 18.1 Organ injury scale for spleen, liver, and kidney
AIS abbreviated injury scale
aAdvance one grade for bilateral injuries up to grade III
Source: Tinkoff G, Esposito GJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Databank. J Am Coll Surg. 2008;207:646–55, reprinted with permission from Elsevier
Children who fail non-operative management typically do so secondary to ongoing hemorrhage or peritonitis. Failure due to hemorrhage is apparent based on physiologic deterioration or ongoing transfusion requirements. Those who fail due to the evolution of an intra-abdominal process such as hollow organ injury with perforation can be more difficult to detect. These patients require constant vigilance and frequent re-examination of the abdomen. Blood in the abdomen or contusion of the abdominal wall will cause tenderness to exam but are not necessarily indicative of the need for an operation. This must be distinguished from a progressive worsening of pain or tenderness suggesting peritonitis and a need for laparotomy.
Missed injury is the nemesis of the trauma surgeon. In the patient with a solid organ injury, there should also be concern for an associated hollow viscus injury. Fortunately, such associated injuries are uncommon and correlate more with the multiplicity of injuries (spleen and liver, kidney, spleen) rather than the severity of the individual organ injury. And, when a hollow viscus injury does occur and is missed on initial work-up, morbidity and mortality are not significantly increased by delay in diagnosis or treatment.
Controversy continues regarding the optimal transfusion threshold for failure of non-operative management in this patient population. It is generally accepted that if the transfusion requirement exceed 40 mL/kg, intervention is indicated. However, this criterion must be considered in context. The patient who requires 40 mL/kg of blood in the first several hours of care is quite different than one who requires the same volume transfused over several days. For patients requiring transfusion, we generally target a post-transfusion hemoglobin of 10 g/dL.
Accepted algorithms, most based on the American Pediatric Surgical Association’s guidelines, are employed in the management of this patient population (Table 18.2). These algorithms base the care of the patient on the anatomic grade of injury (as demonstrated by CT) and include specific recommendations regarding the need for ICU monitoring, bed rest, fluid resuscitation, repeat imaging, and time to discharge. Generally, lower grade injuries (1–3) can be managed on the ward with initial bed rest followed by a scheduled escalation of activity. Higher grade injuries (4 or 5) are managed in the ICU for close physiologic monitoring and hemoglobin checks. The management algorithms also address activity restrictions following hospital discharge. Lower grade injuries typically have a period of limited activity (“house arrest”) of 2–3 weeks, followed by a period of limitation in contact sports of 2–3 months. Activity restrictions for higher grade injuries are typically 3 weeks of house arrest and 3 months of only non-contact sports. Routine follow-up imaging (ultrasound or CT) has not been shown to be of benefit and is therefore not recommended. However, a change in clinical condition (worsening pain, pallor, other symptoms) necessitates additional imaging. These algorithms are frameworks for care and well validated in the pediatric population. However, not all children will fit or adhere to a pathway and individualization (repeat CT scan for pain or prolonged bed rest) might be indicated. While the plan of care is based on the grade of injury, the need for intervention should be based on the physiologic response of the patient to the injury.
Table 18.2 Treatment algorithm for abdominal solid organ injuries
Source: Modified from Stylianos S. Evidence-based guidelines for
resource utilization in children with isolated spleen or liver injury. The
APSA Trauma Committee. J Pediatr Surg. 2000;35(2):164–7
Spleen
The spleen is the most commonly injured intra-abdominal organ. Splenic trauma is suspected in any blunt trauma to the lower chest or upper abdomen. Patients often demonstrate pain and tenderness in the left upper quadrant, abdominal distension, tachycardia, and pain referred to the left shoulder. Lower rib fractures should raise suspicion for underlying injury as they suggest that a significant transfer of energy has occurred.
Most children with splenic injuries can be safely treated without operation or transfusion. Although associated with higher grades of injury, a contrast blush on the CT scan does not mandate embolizatioor does it predict the need for surgical intervention in children with blunt splenic trauma. Severe splenic injuries with a blush on the initial CT scan can be successfully treated nonoperatively as guided by the stability of the patient. However, patients with evidence of ongoing hemorrhage should be considered for angioembolization (Fig. 18.3). Selective embolization of arterial branches can preserve functioning spleen, but evaluation of splenic function is difficult and these patients might require vaccination even if they avoid splenectomy. Embolization is associated with an increase in the need for blood transfusion, but this appears to be due to the severity of the injury, not the intervention itself.
For patients with ongoing hemorrhage or physiologic deterioration, laparotomy is indicated. Depending on the condition of the patient, attempts at splenic preservation should be pursued. Many techniques for splenic salvage have been described, including the use of an absorbable mesh to wrap the damaged organ and arrest bleeding through a tamponade effect. Hemostatic agents (thrombin, oxidized cellulose, hemostatic matrix gel) are also sometimes useful. If splenectomy is necessary, patients should receive vaccinations (against encapsulated organisms, Streptococcus pneumoniae, Hemophilus influenzae, and Neisseiria meningitides) to reduce the risk of overwhelming post-splenectomy infection (OPSI). Although OPSI is estimated to be rare (0.23–0.42% per year), it can be lethal. The risk for OPSI has been reported to be higher in children than in adults. In addition to vaccination, most recommend maintenance of daily oral penicillin until the age of 18 years. Complications of nonoperative management include abscess, delayed hemorrhage, or chronic pain but are acceptably uncommon.
Fig. 18.3 Algorithm for management of solid organ injury in children that incorporates angioembolization as an alternative to surgery in stable patients who have evidence of ongoing bleeding. Note hemodynamically unstable patients should undergo urgent laparotomy rather than attempts at embolization
Liver
Liver laceration after blunt trauma is the second most common abdominal injury in pediatric trauma, but the most likely intra-abdominal injury to result in death. Non-operative management strategies, while typically successful, are not always free of complication. Delayed hemorrhage, biloma, and hemobilia have all been reported in patients managed non-operatively. A small proportion (5–10%) of children will require laparotomy. Liver injuries necessitating operation are typically higher grade and can be quite challenging to the surgeon.
Experience in adults has demonstrated the utility of damage- control techniques, which have been useful in the pediatric population as well. This management approach involves an initial abbreviated laparotomy with the goal of hemorrhage control and limitation of soilage rather than definitive repair of injuries. The abdomen is packed with laparotomy pads to tamponade bleeding and the abdomen closed temporarily. Patients are then taken to the ICU for rewarming, correction of coagulopathy, and ongoing resuscitation. Following a period of stability, typically 12–24 h, the patient returns to the operating room for definitive repair of injuries. Angioembolization may also be of use for the control for persistent bleeding.
Kidney
The kidney is the third most commonly injured solid organ in blunt trauma. As with liver and spleen injuries, the majority of kidney injuries are amenable to a non-operative strategy. Because of the potential for injury to the collecting system, renal injuries pose unique challenges. With higher grade injuries (3–5), there is a risk of delayed extravasation of urine. For such injuries, follow-up CT scan at 48–72 h postinjury is recommended. Even in the face of significant extravasation, patients are likely to respond to closed techniques (ureteral stenting, percutaneous nephrostomy) obviating the need for laparotomy and minimizing possible renal loss. Selective embolization can also play a role in control of hemorrhage and organ preservation. Interventional techniques might also be of use ion-hemorrhagic vascular injuries to the kidney. If laparotomy is necessary, attempts at salvage should be pursued if feasible.
FIGURE . Severe right kidney disruption, resulting
in a large perirenal hematoma, is seen on this CT scan after
intravenous administration of a contrast agent.
Pancreas
Pancreatic injuries are comparatively rare, but present challenging management issues. The pancreas might be injured when a child sustains a focused blow to the mid-abdomen (fist, handlebar), which crushes the body of the pancreas against the vertebral column. A child who presents immediately after injury is often deceptively asymptomatic and wellappearing until the destructive effects of pancreatic enzymes result in local tissue injury. As such, many pancreatic injuries are missed initially due to a paucity of symptoms. At times, assessment of the abdomen happens so efficiently, that edema planes resulting from an enzyme leak have not yet occurred and even the CT scan will be falsely reassuring. Persistent symptoms and clinical concerns warrant follow-up imaging (CT or ultrasound). Computed tomography (with IV contrast timed to highlight the pancreas) will reveal the injury.
Treatment of pancreatic injuries depends on the severity of injury and the timing of presentation. Minor injuries without evidence of major duct disruption will typically respond well to non-operative management. More significant injuries involving the main pancreatic duct respond variably to nonoperative management. The rate of complications (pseudocyst formation, pancreatic necrosis, abscess) is much greater when the duct has been disrupted. If uncertainty exists regarding the integrity of the main pancreatic duct, ERCP allows definitive delineation of the duct anatomy and allows stent placement even in young children. Non-operative management typically includes a period of bowel rest to minimize pancreatic stimulation. The diet is then gradually liberalized and pancreatic enzymes followed to detect pancreatitis.
In general, complete or near-complete pancreatic transection in stable patients is managed with spleen-preserving distal pancreatectomy. Long-term functional results of distal pancreatectomy are generally excellent. Pancreatic exocrine insufficiency is rare and there are no reported cases of diabetes or other endocrine dysfunction.
Bladder
Most bladder injuries result from blunt trauma. Children are at greater risk of bladder injury because the bladder resides out of the pelvis and is thus less well protected. Any lower abdominal blunt trauma (such as a lap belt injury) can lead to rupture of the bladder.
Injury to the bladder is suggested by the injury mechanism, the presence of blood from the urethra or gross hematuria, abdominal pain, and presence of intraperitoneal fluid on imaging studies. The diagnosis is confirmed by conventional cystogram but CT cystogram with delayed and postvoid images might be more accurate.
Isolated extraperitoneal bladder perforation can be managed with Foley catheter drainage for 7 days, antibiotics, and pain control. Intraperitoneal bladder injury is managed by laparotomy and primary repair. A layered method using absorbable suture is most commonly used. Female urethral and bladder neck injury can occur with pelvic fracture, presents with gross hematuria or blood at the introitus, and requires operative repair for avulsions and longitudinal lacerations. These patients are at risk for significant sexual and lower urinary tract dysfunction and require careful follow up by an experienced pediatric urologist.
Duodenum and Small Intestine
Intestinal injuries comprise up to 15% of intra-abdominal injuries in children. While the duodenum is most commonly injured after blunt trauma in children, small bowel injuries, such as mesenteric avulsion, enterotomy, and even transections, are also well described. Overall, intestinal injuries in children are rare, but still carry a high mortality risk (>25%) likely due to the high energy transfer required to produce these injuries. Like pancreatic injuries, bowel injuries can easily be missed on initial assessment due to a paucity of clinical findings. Serial physical exams and a high index of suspicion are necessary to make the diagnosis wheot apparent on initial evaluation.
Duodenal injuries result from a similar mechanism (epigastric blow from a handlebar or fist) and are frequently associated with pancreatic injuries. Diagnosis is confirmed by CT (or UGI) demonstrating intramural hematoma and proximal dilation. These injuries are typically managed with nasogastric decompression, bowel rest, and parenteral nutrition.
Figure . This child sustained a duodenal hematoma (B, arrow) from a handlebar injury to the epigastrium (A).
A nasojejunal feeding tube can be threaded beyond the relative obstruction caused by the hematoma to allow enteral feedings. Most duodenal hematomas will resolve without late sequelae within 1–2 weeks. Patience is rewarded in the management of these injuries, with well over 90% able to be managed non-operatively. In cases where repair is required (perforation, failure of conservative treatment), primary repair by simple hematoma evacuation or primary closure is usually possible. More severe injuries sometimes require pyloric exclusion or gastrojejunostomy. In contrast, small bowel perforations and transections must be repaired. Any blunt trauma to the abdomen can result in injury to the small intestine but diagnosis is difficult since free air is frequently absent and even CT has low sensitivity for these injuries. The diagnosis should be considered in all patients with a suspicious mechanism (seat-belt sign, handlebar injury, forceful direct blow to the epigastrium), focal tenderness, or intra-abdominal fluid without solid organ injury on CT scan. Limited perforations may be managed with simple repair. More extensive injuries or tissue devitalization from mesenteric injuries should be resected. Stable mesenteric hematomas should not be disturbed if the adjacent bowel is clearly viable. Most small bowel injuries can be managed without diversion.
Colon and Rectum
Injuries to the colon and rectum are relatively uncommon, but like small bowel injuries, operative management is typically necessary. Focal injuries without tissue devitalization can in most cases be managed with simple repair. More extensive injuries however will likely need resection and anastomosis. Criteria outlining those wounds needing fecal diversion are not well established in pediatric trauma, however most will do well with repair alone. Fecal diversion should be considered in the setting of hemodynamic instability, large-volume blood loss, extensive contamination, or when damage-control laparotomy is necessary.
Isolated Abdominal Free Fluid
Free fluid on CT scan in the absence of a solid organ injury raises the possibility of a hollow visceral injury. However, most studies have concluded that laparotomy is not mandated in these situations and that watchful waiting is a safe alternative. If symptoms worsen or the clinical picture is unclear, such patients are candidates, assuming they are hemodynamically stable, for diagnostic laparoscopy to exclude a bowel injury.
Child Abuse
One of the unfortunate aspects of pediatric trauma care is the prevalence of non-accidental injury. Many abused children suffer abdominal injuries. Given the often erroneous history in this setting, a high index of suspicion is necessary to make the diagnosis. It is not uncommon that a young child will present in extremis only to have evidence subsequently of an intra-abdominal injury from non-accidental trauma as the cause.
Impalements
Impalements involving the abdomen pose unique challenges to the healthcare team. Like other penetrating injuries, determination of trajectory and assessment of possible organ injuries is of paramount importance. Diagnostic imaging (beyond plain films) might not be practical if the foreign body remains in situ. Removal of the impaling object however should only occur in the controlled setting of the operating room. The operative team should be prepared to manage major vascular injury and have blood available. Specific management is based on injuries identified at the time of removal.
Penetrating Abdominal Trauma
Penetrating abdominal trauma is less common than blunt trauma and accounts for approximately 14% of abdominal trauma in children. It is frequently due to a fall onto sharp objects, a cow gore, gunshot wound, and, rarely, a stab injury. Treatment depends on the penetration of the peritoneum. After adequate resuscitation and stabilisation, the wound is explored under general anaesthesia to identify peritoneal breach.
If the peritoneum is breached, a formal laparotomy is required, through a separate incision, to identify and treat organ injuries. If a peritoneal breach is not detected (or a breach is only suspected), DPL is done and a laparotomy is performed if it is positive. Where available, a triple-contrast CT scan (oral, IV, plus bladder contrast) should be done. If the CT scan is negative, the patient is observed for 24–48 hours; if it is positive, a laparotomy should be done.
Figure. In some patients it is not always clear whether a significant intestinal injury has occurred from either blunt or penetrating trauma. Dingnostic laparoscopy is a useful technique in these patients. A, Perforation of the bowel from penetrating trauma is seen at laparoscopy. This was closed primarily. B, Full-thickness injury to the colon (arrow) in a patient with blunt trauma is shown. The laparoscopic approach was converted to an open operation for treatment of this injury.
In stab injuries to the flank or back, a CT scan is done. If a CT scan is not available, a laparotomy is done to exclude injuries to retroperitoneal organs. DPL is usually not useful. If there is obvious organ evisceration, the organ is covered with clean moist gauze and polythene to decrease desiccation, loss of fluid, and hypothermia.
Whenever laparotomy is performed, it must be thorough to avoid missing any injuries. Injuries to solid organs or the gastrointestinal tract are treated as in blunt trauma. Tetanus prophylaxis should be given if the child is unimmunised or if the immunisation status is unknown.
Anorectal Injuries
Anorectal injuries are not common in children, but they may be associated with significant morbidity if not identified and treated properly.12–13
Most anorectal injuries are due to penetrating trauma, and the penetrating objects often are potentially contaminated and capable of introducing infections, particularly tetanus.
Presentation
There may be a history of falling onto a sharp object or falling astride an object. Motor vehicle crashes may also produce anorectal injury. The common symptoms include:
• rectal bleeding;
• vaginal bleeding;
• vaginal discharge; and
• abdominal pain and tenderness.
Fever, if present, is an indication of intraperitoneal involvement or late presentation. Careful abdominal examination should be done to exclude intraperitoneal involvement. Examination of the perineum and anorectum after trauma is usually limited due to pain and tenderness. As such, adequate evaluation should be done under general anaesthetic and good lighting.
Evaluation
Under general anaesthetic, careful and meticulous examination of the perineum, anorectum, and vagina should be done. The aim of this evaluation is to ascertain the nature and extent of injury. The examination begins with inspection of the vagina, with particular attention to the posterior vaginal wall, which is frequently injured in girls. Any laceration in the perineum is noted, and the depth is ascertained. The anorectum is then examined; this may require proctosigmoidoscopy. Once the evaluation is complete, the injury should be graded (Figure 29.4).
Figure . This teenager developed this full-thickness straddle rectal injury after falling off a trampoline. It was possible to close the injury over drains placed in the perirectal tissues. He has recovered uneventfully with full continence.
Figure 29.4: Grading of anorectal injuries.
Treatment
The treatment of anorectal injuries is summarised in Figure 29.5. The wound should be carefully explored. All dead or devitalised tissue should be completely excised. The wound should be repaired if accessible. Adequate drainage of the wound (perirectal) may be necessary. Laparotomy is required if intraperitoneal rectal injury is present. A protective (proximal) colostomy may be necessary in some situations. Tetanus prophylaxis and broad-spectrum antibiotics should be given. Sphincteric function should be evaluated after wound healing is complete.
Figure 29.5: Treatment of anorectal injuries (IR: intraperitoneal rectum; ER: extraperitoneal rectum).
Thoracic Trauma
Clinically significant thoracic trauma occurs in 4–6% of injured children. Although the frequency of penetrating injuries continues to increase in both urban and rural centers, injuries due to blunt trauma, primarily from motor vehicle crashes and pedestrian trauma, predominate, accounting for more than 85% of cases. Isolated thoracic injuries are rare in children, and instead occur much more commonly in association with multi-system trauma. When present, they are a marker for severe, life threatening injuries. In fact, regardless of the mechanism, an associated thoracic injury more than triples the risk of death. Data from the National Pediatric Trauma Registry reports an overall mortality of 15% for children with blunt thoracic injury.
Children are at greater risk for thoracic trauma for several reasons. Incomplete rib ossification results in increased chest wall compliance and more efficient transmission of mechanical energy to internal organs without skeletal injuries or obvious external findings. When injury to the thoracic cage is present, it implies that significant blunt force energy was involved. The increased mobility of mediastinal structures places children at greater risk for the development of a tension pneumothorax, and significant physiologic compromise or cardiovascular collapse after simple pneumothorax. In addition, because of a relatively small size to body surface area, children are at higher risk for injuries to multiple organ after blunt trauma.
The initial management of a child with suspected thoracic injury should follow standard Advanced Trauma Life Support (ATLS) protocols. A positive physical exam (stridor, chest pain, tracheal deviation, distended neck veins, abnormal or diminished breath sounds, crepitus or dullness to percussion) in the appropriate clinical setting is highly suggestive of thoracic injury, but is neither sensitive nor specific. Before trying to completely define the injury, the priority should be to secure the airway, to make sure the patient is breathing, and to stabilize the circulation. Many thoracic injuries will require definitive treatment during the primary survey. All penetrating wounds should be identified as the patient is exposed during resuscitation to help determine trajectory and, in turn, potential organ injuries. In general, radiographic imaging is required to confirm diagnosis in children sustaining thoracic trauma.
Thoracic injuries in children can be categorized by
location:
I. Chest Wall
a. Flail chest
b. Open pneumothorax
c. Rib fracture
d. Traumatic asphyxia
II. Pleural Cavity/Pulmonary Parenchyma
a. Tension pneumothorax
b. Hemothorax
c. Simple pneumothorax
d. Pulmonary contusion/laceration
e. Diaphragmatic injury
III. Mediastinum
a. Pericardial tamponade
b. Aortic/great vessel injury
c. Tracheobronchial injury
d. Cardiac contusion
e. Esophageal injury
Diagnosis
The diagnostic workup of a child with suspected thoracic trauma begins with a supine antero-posterior chest radiograph.
Most thoracic injuries can be identified and managed on the basis of this standard plain film. Although the issue has been raised in several small series of blunt trauma patients, there is no consensus as to whether a thorough physical examination can safely obviate the mandatory screening chest radiograph in children. The treating physician must be cognizant of the normal anatomic variants of childhood, such as the relatively large thymic silhouette, which can make interpretation of the radiograph much more difficult. Nevertheless, such diagnostic difficulties often make it necessary to proceed with more advanced imaging studies in the evaluation of children with suspected thoracic trauma in order to guide appropriate management.
Figure : Chest radiograph of a ruptured left hemidiaphragm, with displacement of the heart and mediastinum to the right.
Figure : Chest radiograph of a ruptured left hemidiaphragm, with displacement of the heart and mediastinum to the right.
Helical CT and CT angiography of the chest can better elineate injuries identified on plain radiographs. These imaging modalities, however, are not necessary in the majority of children with blunt thoracic trauma and should not be used for screening purposes. In hemodynamically stable children with penetrating injuries, CT can often better define injuries and ballistic trajectory to guide management decisions. A modified focused abdominal ultrasound for trauma (FAST) of the thorax has reported utility for the immediate diagnosis of life threatening injuries such as pericardial effusion, pneumothorax, and hemothorax in the unstable adult trauma patient. Due to limited availability and poor sensitivity for abdominal injuries, its use as a screening test in children has not yet been as enthusiastically received by pediatric trauma surgeons. Two-dimensional transthoracic or transesophageal echocardiography can assist with the diagnosis of pericardial effusion and tamponade as well as the detection of heart wall motion abnormalities in children with myocardial contusions. A water-soluble contrast esophagram is sometimes necessary in cases of suspected esophageal perforation.
Treatment
Injury to the lungs and pleural space are the most common thoracic injuries in children. Pneumothorax occurs frequently after both blunt and penetrating injury and can typically be managed by standard tube thoracostomy. Aggressive management is warranted due to the increased risk of tension pneumothorax physiology. Needle decompression of a tension pneumothorax may be required prior to definitive management with tube thoracostomy. Open pneumothorax (sucking chest wound) should be initially managed with a semi-occlusive dressing prior to tube thoracostomy.
Open pneumothorax (sucking chest wound) in a child who was impaled by a door handle along his right lateral chest wall.
Occasionally, an asymptomatic pneumothorax will be identified incidentally on the lower chest images obtained during an abdominal CT scan. Although these “occult” pneumothoraces rarely become clinically significant and thus infrequently require tube thoracostomy, the patient should be monitored with serial examinations and follow-up chest X-rays, especially if positive pressure ventilation is required.
Pulmonary contusions are commonly identified by chest X-ray and confirmed by CT (Fig. 19.1). Due to the lack of comorbidities and excellent pulmonary reserve, these injuries are seldom of clinical significance. Extensive or multilobar injuries, however, can lead to respiratory compromise requiring aggressive support with mechanical ventilation. Progression to respiratory distress syndrome has also been observed. Children with minimal symptoms but significant X-ray findings should therefore be monitored closely. Excessive intravenous fluid resuscitation can worsen pulmonary function in these patients. Late complications also occur, including pneumatoceles, which are due to air accumulation within an associated pulmonary laceration. These complications are rarely of clinical consequence but take weeks or months to completely resolve radiographically.
Fig. 19.1 Patchy bilateral infiltrates of lung bases representing pulmonary contusion in patient with blunt chest injury
Cardiac contusions likely occur with a greater frequency after blunt trauma than is clinically appreciated. The excellent cardiac reserve of children masks the typical signs and symptoms of this injury seen in adults. An electrocardiogram should be obtained in all children to identify abnormalities in conduction, rhythm, and rate. Hemodynamically stable children iormal sinus rhythm may be monitored without further work-up, as complications from this injury are typically evident immediately. Serum creatine phosphokinase-MB (CPK-MB) and cardiac troponin levels (T and I) will demonstrate enzyme leak from injured myocardium but have limited clinical utility in routine patient management. Two-dimensional transthoracic echocardiography or TEE will demonstrate heart wall motion abnormalities, pericardial effusions, pericardial tamponade and valvular dysfunction in symptomatic children, and can guide pharmacologic support and, rarely, surgical intervention. Finally, central venous cannulation can be helpful in the resuscitation of children with functional compromise.
Tracheal and major bronchial injuries are rare in children and are typically the result of blunt chest trauma with a closed glottis. Laceration of the membranous portion of the trachea is the most common injury.
Figure. CT scan of the chest in a child who sustained penetrating trauma. This image was taken from the upper thoracic region. Note the air in the subcutaneous tissue and mediastinum. This child was found to have a tracheal and an esophageal injury.
Numerous reports have described successful “conservative” management of lacerations of the membranous trachea by endotracheal intubation (stenting) and broad-spectrum antibiotic coverage. However, unstable patients with significant air leak and respiratory compromise require operative intervention for repair. Bronchial injuries are characterized by persistent pneumothorax and often massive air leak following tube thoracostomy. The “fallen lung sign” on chest radiographs after tube thoracostomy is suggestive of this injury.
Figure. Chest radiograph of a 2-year-old patient who was run over by an automobile. Note the persistent large right pneumothorax despite the adequate placement of a chest tube. This patient was found to have a complete disruption of the right mainstem bronchus at the orifice of the right upper lobe bronchus
These injuries uniformly require operative repair and ofteecessitate pulmonary resection. Bronchoscopy, in a controlled setting, can help to localize the site of injury. Extracorporeal life support has been used for stabilization and salvage in patients who are in extremis. Long-term follow up with serial bronchoscopy is required in all patients with tracheo- bronchial injuries to identify subsequent airway stenosis. Traumatic asphyxia may also result from compressive chest trauma applied against a closed glottis. Patients typically present with mental status changes and respiratory distress. The diagnosis is confirmed by the presence of edema and cyanosis with petechiae of the upper chest, neck and face. Subconjunctival and retinal hemorrhages may also be seen.
Treatment is supportive but must include a thorough assessment to exclude other injuries. Despite the dramatic clinical presentation, traumatic asphyxia is rarely life threatening. However, an occasional patient will require ventilatory support with positive end-expiratory pressure (PEEP) for significant pulmonary contusions or other associated injuries.
Oesophageal Injuries
Fortunately, due to the location of the oesophagus, injuries to it are rare. Transmitted pressure from the stomach may cause either Mallory- Weiss bleeding (if the lower oesophageal sphincter is closed) or the more sinister Boerhaave syndrome, characterised by perforation of the lower oesophagus into the left chest cavity (if the upper oesophageal sphincter is closed). Penetrating injuries may cause oesophageal injuries if they are transthoracic. Radiographic contrast studies and/or endoscopies are strongly advocated in these cases. A nonionic contrast material should be used.
The management of the oesophageal injuries depends on the nature of the injury, the timing of presentation, and the location. With the exception of major (high-velocity) gunshot injuries, the majority can be repaired primarily within 24 hours of the injury. Beyond the first 24 hours, the operative strategy may include oesophageal diversion, exclusion, T-tube drainage, or even total oesophagectomy.
Cervical oesophageal injuries
Cervical oesophageal injuries rarely represent a large problem because leakage from a repair produces localised tissue infection or abscess, which can be drained externally.
Thoracic oesophageal injuries
Thoracic oesophageal injuries are notorious for the fast spread of saliva, food, and acid from the stomach through the injury into the chest, able to cause a rampant and usual lethal mediastinitis. Oesophageal diversion might be indicated in these cases.
Abdominal oesophageal injuries
Abdominal oesophageal injuries will usual present as an acute abdomen and will require a laparotomy for repair.
Esophageal perforation is rare following blunt thoracic trauma and is more likely the result of penetrating mechanisms. Diagnosis is best made with water-soluble contrast esophagram. Esophagoscopy is a complementary study and may increase the diagnostic yield. Thoracotomy and primary repair is recommended for injuries diagnosed early with minimal contamination. Pleural and mediastinal drainage is required. Esophageal perforation diagnosed late (more than 24 h after injury) may require esophageal diversion with a cervical esophagostomy to allow for healing.
Injury to the thoracic duct may occur anywhere along its intrathoracic course. Non-bloody pleural fluid, high in triglyceride levels and lymphocyte counts should raise suspicion. Although extremely rare, both blunt and penetrating mechanisms have been reported. Child abuse should be suspected in a child with associated rib fractures or an inconsistent history. Management typically requires tube thoracostomy to allow the lung to reexpand. Dietary modification with restrictions to medium chain triglycerides or a period of gut rest and total parenteral nutrition may facilitate closure of the leaking duct. Successful closure with octreotide, to limit chyle production, has been reported. Operative intervention should be reserved for children with persistent leakage over multiple weeks who fail conservative managements. Thoracic exploration via thoracoscopy or thoracotomy with pre- and intraoperative administration of cream into the gastrointestinal tract should demonstrate the site of injury and allow for ligation. Mechanical pleurodesis may also be required to obliterate the pleural space in children who fail other managements.
Injury to the ribs and thoracic cage in children is a rare consequence of blunt trauma. A child’s skeletal immaturity results in increased chest wall compliance and typically allows for transmission of impact energy through the chest wall to be absorbed by internal structures. Rib fractures represent a sign that significant mechanical force was delivered and, as such, are a marker of potentially severe internal injuries.
Fig.This 7-year-old was involved in a motor vehicle accident. The patient was not wearing restraints at the time of injury and had multiple other injuries. A, Multiple rib fractures and pneumothorax with collapsed right lung (arrows) are seen. B, A chest tube has been placed for initial management. C, Several days later there has been complete re-expansion of the lung and resolution of the right lower lobe pulmonary contusion.
Rib fracture location is important to note during the work-up. Fractures to the lower ribs are associated with upper abdominal solid organ injuries and are an indication for further workup with an abdominal CT. First rib fracture and sternal fractures have been associated with injuries to the mediastinum, particularly the aortic arch, and should be followed up with a chest CT. Posterior rib fractures are associated with non-accidental trauma. These injuries are often found in various stages of healing during skeletal surveys obtained in the evaluation of non-accidental trauma. Most rib and sternal fractures require only supportive management and pain control. Rarely, a displaced sternal fracture will require open reduction and internal fixation.
Flail rib segments result from ribs injuries with two or more points of fracture and represent the most severe injury to the thoracic cage. Respiratory embarrassment can result from paradoxic chest wall motion and ineffective respiration, but is more commonly due, in these injuries, to the underlying pulmonary contusion. Supportive management with aggressive analgesia, including thoracic epidural anesthesia, and positive pressure ventilation, may be necessary. Operative rib fixation is rarely needed.
Injury to the diaphragm occurs most frequently from severe blunt abdominal and penetrating thoraco-abdominal trauma. Recent series document that both hemidiaphragms are equally at risk.
Figure. Bilateral diaphragmatic rupture after blunt abdominal trauma. The hemostats have been placed on the lower rim of the diaphragmatic rupture.
Most diaphragmatic injuries can be diagnosed by standard anteroposterior radiographs demonstrating an elevated hemidiaphragm, herniated bowel loops or a nasogastric tube tip within the chest. Computed tomography with coronal and sagittal reconstructions may assist with diagnosis in questionable cases. Although thoracoscopic repair has been described, laparotomy is favored due to the high (greater than 50%) likelihood of associated hollow viscus injury.
As in adults, blunt injury to the aorta and great vessels occurs most often following rapid deceleration. Diagnosis, in children with a concerning mechanism, should be suspected with widening and abnormal contour of the mediastinum on anteroposterior chest radiograph. The normal thymus gland in young children often makes interpretation of these X-rays difficult for the inexperienced. Helical CT and TEE are accurate in diagnosing this injury, and have replaced traditional angiography as a screening tool.
Figure. An 8-year-old patient presented with injuries from being an unrestrained passenger in a motor vehicle accident. A, On the chest radiograph, note the widened mediastinum and loss of definition of the aortic knob (arrow). There is also a right pneumothorax that was treated with tube thoracostomy. B, An aortogram shows a pseudoaneurysm (arrow) at the location of the ligamentum arteriosum just distal to the left subclavian artery, representing the partial transection of the descending aorta at this point.
Operative management with and without left heart bypass as well as endovascular stenting has reported success in case reports.
Unfortunately, penetrating thoracic trauma has increased in frequency in the pediatric population across all ages. Overall, 50% of children sustaining penetrating injury to the thorax will require surgery. The need for surgical intervention increases to over 90% in children presenting with unstable vital signs. After either blunt and penetrating mechanisms, children with a significant hemothorax and thoracostomy tube drainage greater than 15–20 or 2–3 mL/kg over 3 or more hours, require thoracotomy for hemorrhage control. Children who are hemodynamically stable should undergo radiographic imaging to identify injuries.
The radiographic work-up of a child with penetrating thoracic trauma typically begins with standard anterior-posterior plain radiographs. Use of radio-opaque markers over or adjacent to the wounds and additional views can assist with the determination of ballistic trajectory which may, in turn, help define injuries. Intravenous contrast-enhanced helical CT scanning is also effective in evaluating transthoracic gunshot wounds. Positive results may warrant immediate operative intervention or further radiographic work-up with a water soluble contrast esophagram, arteriogram, bronchoscopy or echocardiography. Children with negative scans can be safely observed in a monitored setting without further evaluation. The shoulders and upper arms should be included with wounds of the torso and are considered at marker for potential associated intrathoracic injuries (Figs. 19.2 and 19.3).
Fig. 19.2 Massive hemopneumothorax in hemodynamically stable patient with stab wound to left shoulder
Fig. 19.3 Plain roentgenogram of humerus with wound marker in same patient in Fig. 19.2
Hemodynamically unstable patients with penetrating thoracic injuries require immediate operative exploration, which should not be delayed by radiographic imaging.
Simple pneumothorax and hemothorax are the most common injuries due to penetrating thoracic trauma. The majority of these may be managed with tube thoracostomy alone. Cessation of air-leak and bleeding, along with full re-expansion of the lung and complete evacuation of the pleural space are all encouraging signs to guide therapy. Failure to improve with pleural space decompression warrants repeat thoracostomy or operative intervention. Thoracoscopy and thoracotomy both have utility in the management of selected cases. Pulmonary debridement, wedge resection, tractotomy, lobectomy and pneumonectomy may be necessary depending upon the operative findings.
Penetrating injury to the anterior thorax between the Nipple lines and between horizontal lines drawn through the manubrium and inferior costal margin (“the box”) requires evaluation for potential cardiac and mediastinal injury. Hemodynamically stable children may be evaluated with CT-angiography and echocardiography. Many children will require a formal subxiphoid or transdiaphragmatic pericardial window. A positive pericardial window mandates sternotomy, pericardotomy and exploration of the pericardial sac for pericardial or cardiac injury.
When managing a child with a penetrating thoracic injury, the potential for injury outside of the thorax must also be recognized. The dome shape of the diaphragm allows for extension of the peritoneal cavity within the lower thoracic cage. Penetrating chest injuries below the level of the nipples or the tip of the scapula suggest the possibility of sub-diaphragmatic injuries. Thoracic and abdominal CT may suggest intraperitoneal injury with the demonstration of blood or free air in the abdomen but does not always define the injury, especially if a hollow viscus is involved. The hemodynamically stable child with a penetrating injury to the liver in which the trajectory of the missile or knife is defined may be safely observed, while significant hemoperitoneum or a CT evidence of extravasation is often an indication for operative intervention. Diagnostic laparoscopy or thoracoscopy is of utility in hemodynamically stable patients in whom diaphragmatic injury and concomitant intraperitoneal injury cannot be excluded by other imaging modalities. Exploratory thoracotomy and/or laparotomy are required in the hemodynamically unstable patient.
The role for emergency department thoracotomy in children
remains undefined. Despite improved survival in children sustaining non-traumatic cardiac arrest, the outcome following emergency department thoracotomy for traumatic arrest continues to be no different from that in adults. Given this poor outcome, emergency department thoracotomy should be reserved for those children sustaining penetrating trauma who present with signs of life and develop a loss of vital signs in the trauma bay during resuscitation. Emergency department thoracotomy is futile for children who present with an absence of vital signs of longer duration and those who arrest from blunt mechanisms.
