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Interact CardioVasc Thorac Surg 2008;7:1031-1034. doi:10.1510/icvts.2008.184283 © 2008 European Association of Cardio-Thoracic Surgery
Experiences in severe chest trauma of children in 20 years
a Department of Cardiothoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410007, P.R. China Received 21 May 2008; received in revised form 6 August 2008; accepted 8 August 2008
Corresponding author. Tel.: +86-13574834746.
Though chest trauma in children is not so common as it is in adults, it may be life-threatening and suggest a high mortality. Herein we retrospected 59 cases of severe chest trauma of children out of 1506 chest trauma cases during 1986–2006 in our department. Features including demographic characteristics, causes, injury types, associated wound had been collected. There were 42 males (71.18%), 17 females (28.82%), 30 cases (50.84%) in the former 10 years and 29 cases (49.16%) in the latter 10 years. The incidence of children's severe chest trauma was 4.9% and 3.2%, respectively, averagely 3.9%. In these 59 cases, 46 cases were treated conservatively, 13 cases were treated by surgery. Four patients died, two in operations, the others attributed to ARDS and cardiac arrest, respectively. The cure rate was 93.22%. Statistic method was used to compare between two groups and with published results in the literature. Children's severe chest trauma is characteristic and different from adults. In our experience, accurate diagnoses and intensive care are very important to save their lives.
Key Words: Chest trauma; Children; Rib fracture; Lung contusion; Heart contusion
The evaluation and treatment of thoracic trauma is a central feature of the early assessment and management of injured children because chest injury may lead to tissue hypoxia [1], though severe chest trauma in children is less common than in adults. Differences in anatomy and mechanisms of injury distinguish childhood injuries from those of adults. They may occur alone or with a component of major multi-system injuries resulting in relatively high mortality. Difficulties may arise when managing thoracic injuries in children. In this retrospective study, we reviewed the experience in a municipal trauma center in China. One thousand five hundred and six chest trauma cases were treated in our department between May 1987 and June 2006. Fifty-nine cases of these were severe chest trauma in children. Information collected from these cases was compared within and with the literature.
We had retrospectively reviewed patients treated for chest trauma at the department of cardiothoracic surgery of First People's Hospital of Chenzhou, China, from May 1987 to June 2006. Among the 1506 patients treated for thoracic trauma, 59 patients were severely injured children (3.92%). Forty-two were males (71.18%) and 17 females (28.82%) (Table 1). Concerning the causes of the injuries, blunt injuries were found in 53 patients (89.83%), penetrating wounds in 6 (10.17%) (Table 2). Injury types included 32 hemo/pneumothoraxes, 31 pulmonary contusions, 24 rib fractures, etc. (Table 3). Statistical method was carried out using  2-test when necessary.
Management of the patients with thoracic injury began with a careful history and physical examination, with their patent airway passage and adequacy of ventilation, blood pressure, pulse and mental state evaluation. The X-ray studies were performed on all of them. Then, full monitorization (including electrocardiography, blood pressure, pulse, temperature, respiratory rate) was performed. Electrocardiography was observed for rhythm and voltage disturbances. Chest computed tomography was only used in selected cases. Primary conservative treatment was performed on all patients initially, and if this treatment was insufficient, surgery was indicated.
Demographic characteristics are described as before (Table 1). There was no statistical significance of incidence discrepancy between the two terms (P=0.085). Injury types of chest trauma are listed in Table 3. No statistical discrepancy was found comparing the two terms of different injury types except for lung contusion. Among 59 cases, 29 were associated with other organ injuries. In 30 cases of the former 10 years, seven cases were associated with abdominal organ injuries, four cases with pelvic fracture, five cases with extremity fractures and one case with great artery injury; while in the latter 10 years, five cases were associated with head injuries, four cases with clavicle fracture, two cases with extremity fractures and one case was associated with abdominal organ injury out of 29 cases. Additionally, there were 12 and six cases presenting tachypnea, disturbance of hemodynamics in the former and latter periods, respectively (Table 4).
Out of 59 cases, 46 patients were treated conservatively. Most of these patients were transfused with blood and intravenous fluid. Bronchial mucus was drained with nasotracheal or bronchoscopic aspiration and so dynpnea was relieved. The nasogastric tube was only inserted in patients who were suspected of having an esophageal rupture. In addition, nasal oxygen, non-steroid anti-inflammatory drugs, analgesic drugs, antibiotics were given to most of the patients. In the former 10 years, six cases were treated by emergent thoracotomy. Two of them were bronchus anastomoses. One patient died during the operation, the other one died of postoperative ARDS. There were two diaphragmatic repairs, one esophagus repair, one heart repair. These were all successful. There were six emergent laparotomies including four liver repairs. One of the liver repair cases was associated with IVC injury and died of massive bleeding during the operation. Another one died of sudden cardiac arrest; one spleen repair and one spleen excision were performed successfully. None was treated by emergent thoracotomy in the latter 10 years. Only one liver repair and one female patient with bilateral multiple rib fracture, lung contusion and hemothorax due to a traffic accident were treated by bilateral thoracic tube drainage (Table 5). The latter one was treated by tracheotomy and mechanical ventilation because of hypoxia and finally discharged uneventfully. In total, 55 cases were cured and discharged. The cure rate was 93.2%.
Children's chest trauma is in various forms with complicated pathophysiological abnormality. It may deteriorate in conditions of associated lung contusion, hemothorax, pneumothorax, hemopneumothorax, rib fractures and other accompanied life-threatening circumstances. Appropriate evaluations, timely diagnoses, interdisciplinary treatments according to different conditions are the key to successful life-saving measures. Children's blunt chest trauma is more commonly seen in the clinic than penetrating trauma [2]. There were 53 blunt chest trauma cases (89.83%) in our subjects, 7 (13.2%) combined thoracoabdominal injury cases, and 13 (22.03%) emergent thoracotomies and/or abdominal surgeries. A traffic accident is the predominant cause of children's blunt chest trauma, accounting for 30 (56.6%) cases in our research, perhaps due to utility of high-speed vehicles, and absent mindness of traffic security. Falls are another very important reason. Twelve cases of the cohort were caused by falls because of the parents or children's own fault. For example, 1 eight-month-old baby fell out of its cradle resulting in rib fracture. Additionally, crushing injuries are also very common. It calls for more attention of schools and relevant organizations. A crowd in a restricted space tends to result in a tragedy of massive crushing injuries. Three cases in the cohort were injured by crushing when going downstairs in a crowd at school. They were admitted in our hospital for traumatic asphyxia. In a word, blunt chest trauma could cause hemothorax, pneumothorax, hemopneumothorax, lung contusion, heart contusion, even rupture of the trachea, bronchi and esophagus, etc. Physicians should pay more attention when a child patient is presenting with tachypnea, pale face, wet and cold skin, tachycardia and incooperation. Children's rib and sternal fractures are less common than adults because they have better flexibility of their bones than adults. In our cases, there was no sternal fracture but 24 rib fracture cases including 5 (40.6%) single rib fracture cases and 19 multiple rib fracture cases. Fractures happened not only in the first, second and third rib protected by scapular bones, but also in the more flexible 8–12th ribs. It was thought that rib fracture may be judged as the standard of valuing the severity of chest injury [3, 4]. Single greenstick fracture needs no specific treatment. However, multiple rib fractures usually mean severe intra-thoracic or abdominal organ injuries which should not be ignored. Children's rib fractures heal up fast with bony callus formation in 2–3 weeks. Thoracotomy reduction and internal fixation were only used in carefully selected cases [5, 6]. Usually, compressive fixation with a cotton cushion on the softened chest area is enough, the key of management is aimed at lung contusion. In multiple injured patients, however, severe blunt chest trauma and especially pulmonary contusion negatively affects outcome with a significant increase in morbidity and mortality [7]. It should be judged as severe chest trauma regardless of symptoms when accompanied by lung contusion. Contused lung tissue may bleed, edema, cause stenosis and obstruction of airway, leading to dysfunction of ventilation and air exchange, ventilation/blood flow disproportion, increased artery shunt in lung, pulmonary diffusion function, impairment of air exchange function, finally causing hypoxia. Children's metabolism is vigorous with considerable consuming of oxygen. So delayed management may result in a bad outcome as hypoxia deteriorates. In the former 10 years, one patient died of ARDS probably resulting from lung contusion. In the latter 10 years, many lung contusion patients were diagnosed timely being correctly attributed to the development of science and technology, application of novel medical equipment and advancement of diagnoses. CT-scan is playing a very important role in this [8]. We have been using CT-scan in such cases: (1) any sign of thoracic injury on CXR; (2) pathologic findings on physical examination of the chest; and (3) high impact force to the chest wall. The standard also complies with efficacy and cost analysis research by Renton et al. [9]. Perhaps this is why patients diagnosed with lung contusion increased sharply in the latter 10 years. In the meantime, CT surgeons are confronted by new challenges in the management of this kind of patient. Mechanical ventilation is encouraged in the management of these patients. Appropriate preventive application of PEEP is advised [7], for it could inflate collapsed alveoli in a small airway, increase lung compliance, improve ventilation/perfusion proportion. There is no role for surgical stabilization for patients with severe pulmonary contusion [6]. It calls for prompt and correct diagnosis, dynamic continuous observation, intensive care, timely management of associated injuries, fluid, electrolytes and acid-base balance to improve the management and increase cure rate. Shock presents when intra-thoracic/abdominal bleeding, obstruction of venous drainage caused by mediastinum translocation in hemo/pneumothorax, dysfunction of a injured heart occur. Prompt diagnoses and correction are necessary to save life. In this cohort, a two and a half-year-old boy was admitted 5 h after a traffic accident. He presented indifferent expression, tachypnea. CXR suggested multiple fractures of the 4–6th ribs with normal heart shadow. CT-scan suggested moderate pleural effusions in right thorax. PE: no apparently different breath sound in bilateral lungs, no heart murmur, HR: 170/min, ECG: ST-T change with low voltage. Myocardial enzyme: CK: 1676 U/l, CK-MB: 88 U/l, AST: 363 U/l, all highly increased. The patient was diagnosed for heart contusion with no doubt. After two weeks' conservative treatment under rigorous surveillance, his heart rate and myocardial enzyme normalized. We thought that the myocardial enzyme test was necessary in diagnosing and treatment of heart contusion. There is no statistical difference in the amount and incidence rate between the two periods while the types of injuries are apparently different. Abdominal injuries, pelvic fracture, extremity fractures account for the major part of the former 10 years, whilst head injuries, clavicle fracture played a big role in the latter 10 years. This suggests the change of trunk and extremities injuries vs. head and neck injuries. Because the major reason, namely, traffic accidents and falls warrant a relatively balanced distribution of body site of injuries [10, 11], we may speculate that patients with head or neck injuries could not sustain until admitted due to underdeveloped emergent medicine 10 years ago. Because of associated injury, head trauma is especially the most important mortality factor [11]. Additionally, four mortalities were from the former 10 years due to non-head injuries. This may further support our speculation. Far fewer operations were performed in the latter 10 years; in our opinion, several reasons might contribute to this. First, CT-scan and other advanced modalities had been wildly used relative to the former 10 years. Second, the advancement of mechanical ventilation and other treatment in the ICU is another important key. Third, more novel medications which may improve the treatment and avoid or decrease the amount of operations had been invented during a 10-year period. The four deaths of the present cohort all occurred in the former 10 years. In a word, we summarize that the percentage of the patients treated surgery-free was 96.45% in our series. Early diagnosis and management are essential to avoid serious complication of chest injury in children. Most chest injuries of children can be precisely diagnosed and treated without surgery, especially when supported by advanced radiology modality and new medications nowadays.
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Abstract
1. Introduction