Thoracic trauma
Key points
Flail chest
Rare in younger children
Always associated with pulmonary contusion
Management:
Analgesia, O2, chest physiotherapy and CPAP
Can fix if unable to wean off ventilation or severe deformity - joint with orthopaedics
1st rib fracture
A large amount of force is required to break the first rib - always be suspicious of other injuries when this is present
Associated with spinal cord injury, subclavian vessel injury, aortic injury, clavicular fracture
Traumatic asphyxia
Caused by a compressive force against chest, creates Valsalva effect
Restricted SVC blood flow and subsequent rupture of capillaries
Findings may be of petechiae upper chest and face
Check neurology, ears - haemotympanum
Haemothorax
Immediate loss of 15ml/kg or ongoing losses of 2-3ml/kg/h for >3h are indications for thoracotomy
Late complications:
Fibrothorax - trapped lung
Empyema
Example chest drain sizes by weight for haemothorax:
3-9 kg: 10-16 Fr
10-14 kg: 16-22 Fr
15-22 kg: 22-28 Fr
23+ kg: 24-40 Fr
Pulmonary contusion
Complications:
Pneumonia
ARDS - 60% mortality
Airway injury
Can present as persistent pneumothorax/pneumomediastinum
Signs on examination could be high riding hyoid + subcutaneous emphysema
Intubate over flexible bronchoscope
Blunt force (acceleration/deceleration) - uncommon airway injuries, but rupture usually within 2cm of carina, and 50% in first 2cm of right main bronchus
Signs on imaging: Collapse of lung away from midline
In theatre: bronchoscope then thoracotomy
Proximal injuries: Repair
Distal injuries: Resect
Traumatic tracheo-oesophageal fistula can occur
For severe facial trauma with airway compromise
Management is cricothyrotomy - must be needle in ages 6-11
Aortic injury
CXR signs:
Left apical cap
Widened mediastinum
Right tracheal shift
Left main bronchus pushed inferiorly
Not sensitive or specific, but high negative predictive value
CT: Pseudoaneurysm at proximal descending aorta - secondary to tearing at ligamentum arteriosum
Management - B blockers
Primary repair - can be delayed. Endovascular grafts may be suitable in children but long term data not available and unlikely
Penetrating oesophageal injuries/rupture
Need to operate
If in neck - left incision anterior to sternocleidomastoid
If in thorax - right thoracotomy
If distal 20% - left 8th intercostal or laparotomy
Explore, debride and close in 2 layers over NG. Cover with pleural flap
If delayed diagnosis and severe mediastinitis - divert proximal with T tube + tie off distal
Diaphragmatic injury
Blunt trauma to abdomen - increased intra abdominal pressure
Repair through midline laparotomy - high rate of associated injuries
Can be repaired via thoracotomy if doing for other injuries
Intercostal hernia
Can present years later
Close with adjacent muscle or fascia - occasionally mesh
Cardiac injuries
Blunt injury:
ECG findings are varied
Check troponin - but not as sensitive as ECG
Echo if suspicious
Referral to cardiac surgery
Can manage from abdomen with subxiphoid pericardial window
Commotio cordis - unique to paediatric trauma. Blunt chest injury at time of repolarisation causes sudden arrest (often ventricular fibrillation)
References
Holcomb and Ashcraft’s Pediatric Surgery, 7th edition, 2020, Chapter 15 Thoracic Trauma
Hirschl, Ron, et al., editors. "Penetrating Thoracic and Mediastinal Injury." Pediatric Surgery NaT, American Pediatric Surgical Association, 2023. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829111/all/Penetrating_Thoracic_and_Mediastinal_Injury.
D'Souza D, Campos A, Elfeky M, et al. Thoracic aortic injury. Reference article, Radiopaedia.org (Accessed on 26 Aug 2024) https://doi.org/10.53347/rID-2171