Initial evaluation and stabilization of children with thoracic trauma
- Donna Reyes Mendez, MD
Donna Reyes Mendez, MD
- Associate Professor of Emergency Medicine
- University of Texas Health Science Center (UTHSC) Medical School Houston
- Section Editor
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The initial evaluation and stabilization of children with thoracic trauma will be reviewed here. Thoracic trauma in adults and specific thoracic injuries in children are discussed separately. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Overview of intrathoracic injuries in children" and "Chest wall injuries in children" and "Pulmonary contusion in children".)
Among injured children, thoracic trauma occurs infrequently. In several observational series describing pediatric trauma victims, between 4 and 8 percent of children sustained thoracic injury [1-4].
Blunt mechanisms are involved in 85 percent or more of cases [1-4]. Most patients are injured as passengers or pedestrians in motor vehicle crashes. Other mechanisms include falls (8 to 10 percent) and abuse (7 to 8 percent). Children with inflicted injuries usually have rib fractures and are young (typically less than three years of age) [5,6]. (See "Orthopedic aspects of child abuse", section on 'Rib fractures'.)
Penetrating thoracic trauma may be caused by a gunshot wound or from stabbing/impalement:
●In the United States, gunshot wounds are the major cause of penetrating thoracic injury among children. A retrospective study describing reports to the National Pediatric Trauma Registry noted that 60 percent of penetrating thoracic injuries were the result of gunshot wounds, while 33 percent were from stab wounds .
- Peclet MH, Newman KD, Eichelberger MR, et al. Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg 1990; 25:961.
- Black TL, Snyder CL, Miller JP, et al. Significance of chest trauma in children. South Med J 1996; 89:494.
- Cooper A, Barlow B, DiScala C, String D. Mortality and truncal injury: the pediatric perspective. J Pediatr Surg 1994; 29:33.
- Holmes JF, Sokolove PE, Brant WE, Kuppermann N. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med 2002; 39:492.
- Bulloch B, Schubert CJ, Brophy PD, et al. Cause and clinical characteristics of rib fractures in infants. Pediatrics 2000; 105:E48.
- Barsness KA, Cha ES, Bensard DD, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma 2003; 54:1107.
- Holland AJ, Kirby R, Browne GJ, et al. Penetrating injuries in children: is there a message? J Paediatr Child Health 2002; 38:487.
- Cooper A. Thoracic injuries. Semin Pediatr Surg 1995; 4:109.
- Sarihan H, Abes M, Akyazici R, et al. Blunt thoracic trauma in children. J Cardiovasc Surg (Torino) 1996; 37:525.
- Sartorelli KH, Vane DW. The diagnosis and management of children with blunt injury of the chest. Semin Pediatr Surg 2004; 13:98.
- Kissoon N, Dreyer J, Walia M. Pediatric trauma: differences in pathophysiology, injury patterns and treatment compared with adult trauma. CMAJ 1990; 142:27.
- Ayling J. An open question. Emerg Med Serv 2004; 33:44.
- Wyrick DL, Dassinger MS, Bozeman AP, et al. Hemodynamic variables predict outcome of emergency thoracotomy in the pediatric trauma population. J Pediatr Surg 2014; 49:1382.
- Rodriguez RM, Hendey GW, Marek G, et al. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med 2006; 47:415.
- Gittelman MA, Gonzalez-del-Rey J, Brody AS, DiGiulio GA. Clinical predictors for the selective use of chest radiographs in pediatric blunt trauma evaluations. J Trauma 2003; 55:670.
- Rajan GP, Zellweger R. Cardiac troponin I as a predictor of arrhythmia and ventricular dysfunction in trauma patients with myocardial contusion. J Trauma 2004; 57:801.
- Hirsch R, Landt Y, Porter S, et al. Cardiac troponin I in pediatrics: normal values and potential use in the assessment of cardiac injury. J Pediatr 1997; 130:872.
- Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma 2003; 54:45.
- Beaver BL, Laschinger JC. Pediatric thoracic trauma. Semin Thorac Cardiovasc Surg 1992; 4:255.
- Dowd MD, Krug S. Pediatric blunt cardiac injury: epidemiology, clinical features, and diagnosis. Pediatric Emergency Medicine Collaborative Research Committee: Working Group on Blunt Cardiac Injury. J Trauma 1996; 40:61.
- Chou TC. Electrocardiography in Clinical Practice: Adults and Pediatrics, 4th ed, WB Saunders, Philadelphia 1996.
- Moore MA, Wallace EC, Westra SJ. The imaging of paediatric thoracic trauma. Pediatr Radiol 2009; 39:485.
- Renton J, Kincaid S, Ehrlich PF. Should helical CT scanning of the thoracic cavity replace the conventional chest x-ray as a primary assessment tool in pediatric trauma? An efficacy and cost analysis. J Pediatr Surg 2003; 38:793.
- Patel RP, Hernanz-Schulman M, Hilmes MA, et al. Pediatric chest CT after trauma: impact on surgical and clinical management. Pediatr Radiol 2010; 40:1246.
- Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons. Committee on Trauma. Practice management guidelines for emergency department thoracotomy. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma. J Am Coll Surg 2001; 193:303.
- Kadish, H. Thoracic trauma. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher, GR, Ludwig, S, Henretig, FM (Eds), Lippincott, Williams and Wilkins, Philadelphia 2006. p.1433.
- TYPES OF THORACIC INJURY
- ASSOCIATED INJURIES
- Initial rapid assessment
- - Airway
- - Breathing
- - Circulation
- - Emergency department thoracotomy
- Physical examination
- Diagnostic studies
- - Laboratory studies
- - Electrocardiography
- - Imaging
- Supportive care
- Chest decompression
- Emergency thoracotomy
- SUMMARY AND RECOMMENDATIONS