Chest Trauma in Children: A Local Experience

Successful Repair of a Subtotal Rupture of Distal Tracheobronchial Tree With Complete Abridgment of the Right Bronchus in a 4-Year-Old Child

Blunt abdominal trauma is the most frequent cause of abdominal injuries in children. The term solid organ injury (SOI) is referred to liver, spleen and kidney. Splenic injuries are the most common. The management of SOI has been motive of discussion for years and has undergone a radical shift in the last decades. Currently, non-operative management is the gold standard of care when circumstances are favorable. In 1977, non-operative management was supported by surgeons in Toronto. Later, the American Pediatric Surgical Association (APSA) pointed that management should be based on imaging findings and CT grading of the American Association for the Surgery of Trauma. However, this caused long stays and unnecessary follow-up imaging. Soon, APSA guidelines were questioned and raised controversy. Finally, hemodynamic status was defined as the main key for taking decisions and ATOMAC guidelines gained support. However, facing a blunt trauma in children is always a challenge. Hemodynamic stability is not easy to define and heart rate and blood pulse are poor markers for stability. This complicates the management of blunt trauma in children. As consequence, it is important that these children are treated in pediatric centers. We report a case of a 15-year-old male who suffered from a blunt abdominal trauma with splenic and renal injuries treated by adult surgeons when playing football. We review the current recommendations for blunt abdominal trauma in children and the differences with adult management. J Med Cases. 2017;8(11):340-346 doi: https://doi.org/10.14740/jmc2901w

BackgroundIsolated duodenal perforation following blunt abdominal trauma is a rare injury in children. Bicycle accidents (falling on to the handlebar) are a frequent cause of blunt abdominal trauma in children and may occasionally be associated with isolated duodenal perforation (IDP). Prompt diagnosis and surgical treatment are vital to prevent increased morbidity and mortality. Case presentationWe report the rare case of an 11-year-old boy admitted for blunt abdominal trauma and treated for an asynchronous double IDP. The first perforation, located on the 2nd/3rd portion of the duodenum, was promptly diagnosed by contrast-enhanced abdominal CT scan after a negative US scan, five hours after injury, and the lesion repaired with a single stitch suture. The second duodenal perforation appeared in the duodenal bulb as a worsening biliary leakage, 48 h after the primary suture of the initial lesion. The perforation was initially seen by digestive endoscopy and sutured in the same way as the first lesion. A third laparotomy was needed 4 days later due to an intestinal obstruction, after which the patient was recovered completely and was discharged home. Discussion and conclusionIDP is a rare consequence of blunt abdominal trauma, and is normally associated with a lesion of other organs, such as the pancreas or bile duct. A delayed diagnosis strongly increases the incidence of morbidity and mortality, and different kinds of surgical management have been proposed, depending on the type of lesion. To our knowledge, this is the first case described in literature of a double isolated asynchronous duodenal perforation following blunt abdominal trauma in children.

Blunt abdominal trauma is the most frequent cause of abdominal injuries in children. The term solid organ injury (SOI) is referred to liver, spleen and kidney. Splenic injuries are the most common. The management of SOI has been motive of discussion for years and has undergone a radical shift in the last decades. Currently, non-operative management is the gold standard of care when circumstances are favorable. In 1977, non-operative management was supported by surgeons in Toronto. Later, the American Pediatric Surgical Association (APSA) pointed that management should be based on imaging findings and CT grading of the American Association for the Surgery of Trauma. However, this caused long stays and unnecessary follow-up imaging. Soon, APSA guidelines were questioned and raised controversy. Finally, hemodynamic status was defined as the main key for taking decisions and ATOMAC guidelines gained support. However, facing a blunt trauma in children is always a challenge. Hemodynamic stability is not easy to define and heart rate and blood pulse are poor markers for stability. This complicates the management of blunt trauma in children. As consequence, it is important that these children are treated in pediatric centers. We report a case of a 15-year-old male who suffered from a blunt abdominal trauma with splenic and renal injuries treated by adult surgeons when playing football. We review the current recommendations for blunt abdominal trauma in children and the differences with adult management. J Med Cases. 2017;8(11):340-346 doi: https://doi.org/10.14740/jmc2901w

Nonoperative management of solid organ injury from blunt trauma in children has focused concern on potential delays in diagnosis of hollow viscus injury with resultant increases in morbidity, mortality, and cost. This study of a large pediatric trauma database will review the issues of difficulty and/or delay in diagnosis as it relates specifically to definitive treatment and outcome. We surveyed 11,592 consecutive admissions to a designated pediatric trauma center from 1985 to 1997 to identify children with documented injury of the gastrointestinal (GI) tract from blunt trauma. The records were extensively analyzed specifically in regard to mechanism of injury, type and site of injury, time to diagnosis, operative treatment, complications, and final outcome. The 79 children identified, 4 months to 17 years old, included 27 females and 52 males. Mechanism of injury included 15 restrained and 7 unrestrained passengers, 15 pedestrians, 15 child abuse victims, 10 bike handlebar intrusions, 8 discrete blows to the abdomen, 4 bike versus auto, 3 falls, and 2 crush injuries. There were 51 perforations, 6 avulsions, and 22 lesser injuries including contusions. Injury of the small bowel was most common, 44 cases, followed by the duodenum, 18 cases, colon, 17 cases, and stomach, 6 cases. In 45 children, diagnosis was made quickly by a combination of obvious clinical findings, plain x-ray and/or initial computed tomographic findings mandating urgent operative intervention. Diagnosis was delayed beyond 4 hours in 34 children, beyond 24 hours in 17 children and was made by persistent clinical suspicion, aided by delayed computed tomographic findings of bowel wall edema or unexplained fluid. The six deaths were caused by severe head injury. Complications included two delayed abscesses and two cases of intestinal obstruction. All 73 survivors left the hospital with normal bowel function. Injury to the GI tract from blunt trauma in children is uncommon (<1%). The majority of GI tract injuries (60%) are caused by a discrete point of energy transfer such as a seatbelt (19%), a handle bar (13%), or a blow from abuse (19%), or other blows and is unique to this population. Although diagnosis may be difficult and often delayed, this did not result in excessive morbidity or mortality. Safe and effective treatment of GI tract injuries is compatible with nonoperative management of most other injuries associated with blunt abdominal trauma in children, while reducing the risk of nontherapeutic laparotomy.

Background/Purpose Among children aged from 1 to 14 years, approximately 50% of mortality is related to trauma. Abdominal injuries account for approximately 10% of trauma deaths in childhood. Child injury has great effects on communities and countries. The agent–host– environment model has been used to describe the epidemiology of communicable diseases. It can be adapted for understanding childhood injuries. This study aims to evaluate the Zagazig University experience with blunt abdominal trauma (BAT) in children in light of the epidemiological (agent–host–environment) model. Patients and methods This study included 590 consecutive patients aged from 1 to 14 years, who were admitted to the Emergency Unit at the Zagazig University Hospital, after BAT incidents in the period January 2006–2010. A predesigned format was used to collect targeted data. Results The study included 590 children with BAT. They made up approximately 18% of total children trauma cases. Multisystem trauma occurred in 72.5% of patients. The causative energy in this study was mechanical energy that was most commonly transmitted through road traffic accidents (55.8%). When mechanisms of trauma were related to age groups, we found that road traffic accidents were significantly more common among children aged from 5 to 14 years (P value < 0.001), whereas falls were significantly more common among children aged from 1 to 4 years (P value < 0.001). The most common physical environment was streets. BAT was more in urban areas (65%) and in low socioeconomic states (67%). Conclusion According to this study, most BAT vulnerable children are boys aged from 5 to 14 years, living in urban areas, and with low socioeconomic status. The agent– host–environment model can be used to study causative and contributing factors to trauma. It can be utilized to structure and plan preventive interventions against BAT in children. Keywords: abdominal trauma, agent–host–environment model, blunt trauma, epidemiological model

Trauma is the leading cause of death in children in developed countries. In tropical Africa, it is only beginning to assume importance as infections and malnutrition are controlled. In developed countries, the availability of advanced imaging modalities has now reduced the necessity for laparotomy to less than 10% following blunt abdominal trauma (BAT) in children. This report reviews the epidemiology, management, and unnecessary laparotomies for pediatric BAT in a developing country in a retrospective review of 57 children aged 15 years or less at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria over 12 years. The average age was 9 years and the male-female ratio 3.8:1. Seventy-four percent (74%) of abdominal injuries in children were due to blunt trauma. The commonest causes of injury were road traffic accidents (RTA) (57%), 88% in pedestrians and 59% in children aged 5-9 years. Falls were the cause of trauma in 36%, 60% of them aged 10-15 years. Other causes of injury were sports in 5% and animals in 2%. Diagnosis was clinical, supported by diagnostic peritoneal lavage or paracentesis. Two patients had ultrasonography, and none had computed tomography. Fifty-three patients had a laparotomy, 2 died before surgery, 1 was managed nonoperatively, and in 1 surgery was declined. There were 34 splenic injuries, 20 treated by splenic preservation, splenectomy in 13, and non-operative in 1. Fourteen gastrointestinal injuries were treated in 12 patients. Of 9 hepatic injuries, 4 were minor and were left untreated, 3 were repaired, 1 was packed to arrest hemorrhage, and a lacerated accessory liver was excised. Four injuries to the urinary tract (bladder contusion 2, bladder rupture 1, ruptured hydronephrotic kidney 1) were treated accordingly. There were 4 retroperitoneal hematomas associated with other intra-abdominal injuries and 2 pancreatic contusions. One lacerated gallbladder was treated by cholecystectomy and a ruptured left hemidiaphragm was repaired transperitoneally. In retrospect, 27 (51%) patients could have been managed by observation (splenic injury 20, liver injury 5, bladder contusion 2) using advanced imaging modalities. One patient developed an intra-abdominal abscess following splenorrhaphy. The average hospital stay was 17 days. Mortality was 8 (14.5%) from gastric perforation (3), liver injury (2), splenic injury (1), and 2 patients died before surgery. BAT in this population results predominantly from RTA in pedestrians. Laparotomy may be avoided in 51% of cases if advanced imaging modalities are readily available.

To determine the pattern, presentation and outcome of gastrointestinal injuries from blunt abdominal trauma in children. A retrospective study. Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Twenty one children managed for gastrointestinal injuries from blunt trauma from 1984-2002. The pattern, presentation, management and outcome of gastrointestinal injuries from blunt trauma. In the 19 year period, 1984-2002, 92 children were treated for blunt abdominal trauma, 21(23%) of who had injuries to the gastrointestinal tract. Three presenting after 24 hours had evidence of peritonitis. In six children with isolated gastrointestinal tract (GIT) injury who presented within two hours, abdominal signs were vague at initial evaluation but became marked over a few hours at repeated examination. In eight with associated intraabdominal injuries, abdominal signs were marked at initial examination and five presented with shock. Free peritoneal air was present on plain abdominal and chest radiograph in three of ten patients, dilated bowel loops in six and fluid levels in one. Diagnostic peritoneal lavage or paracentesis was positive in four patients with isolated GIT injuries and eight with associated intraabdominal injuries. There were 24 injuries in the 21 patients consisting of 15 perforations, five contusions, two seromuscular tears, and two gangrene from mesenteric injury. The small intestine was involved in 11 patients, colon six, stomach five, duodenum one and rectum one. Seven (35%) patients had associated extraabdominal injuries. Treatment consisted of simple closure of perforations, over sewing of contusions, resection and anastomosis for gangrene and repair with protective stoma for the rectal injury. One patient each developed prolonged ileus, urinary tract infection and chest infection, respectively postoperatively. Mortality was 28%, all of who had associated intraabdominal or extraabdominal injuries. Gastrointestinal injury from blunt abdominal trauma in children, though uncommon, carries a high mortality, usually from associated intraabdominal or extraabdominal injuries.

Both blunt and penetrating chest trauma in children are less common than in adults but cause severe acute morbidity and mortality. As the literature suggests, pulmonary contusion is the most common chest injury in children, occurring in more than half of all blunt chest trauma cases. Even patients with blunt injuries are likely to have a longer hospital stay. The difference in physiological and anatomical variations in children compared to adults makes it more difficult from the diagnosis, management, and monitoring perspectives. A thorough physical examination is needed with close clinical monitoring, and additional vigilance is important during the management of a child. The physiologic consequences, such as the dreaded complication of alveolar hemorrhage and pulmonary parenchymal destruction, usually manifest within a few hours of the trauma and can take up to seven days to recover. Hence, timely diagnosis is crucial during the emergency evaluation. The clinical diagnosis can be supported by a special imaging modality in the form of chest computed tomography (CT), which confirms the radiological parenchymal destruction with high sensitivity. Management is mostly supportive to start with and includes high-flow oxygen, ventilatory pressure support as needed for the severity of acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), judicious fluid administration, control of the pain associated with bony and thoracic soft tissue injuries, and careful hemodynamic monitoring for other complications and sequelae likely to develop. Here, we report an interesting case of a 10-year-old male child presenting to the Pediatric Emergency Department with acute moderate-to-severe respiratory distress that developed after two days of a few vomiting episodes along with non-specific lower chest and substernal pain following blunt trauma to the chest. The injury was trivial in nature as described by the father caused by an accidental fall on a small pile of bricks while playing near his home. After triaging under the red category, the child was managed in line with acute respiratory distress. We ruled out pneumothorax, hemorrhagic pleural effusion or pericardial effusion, and other evidence of invasive chest as well as gross abdominal injuries by comprehensive but focused history and clinical examinations, including adjuncts such as point-of-care ultrasound) and chest X-ray (CXR). Although the initial arterial blood gas analyses were suggestive of a mild form of ARDS or ALI by the criteria based on the P:F ratio (PaO2 to FiO2 ratio, which was between 200 and 300 for the case), the CXR and the chest CT revealed that the child had significant lung parenchymal injury in the form of bilateral fluffy pulmonary infiltrates. This case indicates that even a trivial blunt trauma can induce certain mechanisms of lung injury, leading to severe manifestations and sometimes fatal complications such as pulmonary contusion, hemorrhage, and ARDS.

We recently developed a preliminary predictive model identifying clinical and radiologic factors associated with the need for surgery following blunt abdominal trauma (BAT) in children. Our aim in this study was to further validate the factors in this predictive model in a multi-institutional study. A retrospective chart review of pediatric patients from five pediatric trauma centers who experienced BAT between 2011 and 2020 was performed. Patients under 18years of age who had BAT and computed tomography (CT) abdomen imaging were included. Children with evidence of pneumoperitoneum, and hemodynamic instability were excluded. Fisher's exact test was used for statistical analysis of the association between the following risk factors and need for laparotomy: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture (TLF), presence of free fluid (FF), presence of solid organ injury (SOI). A predictive logistic regression model was then estimated employing these factors. Seven hundred thirty-four patients were identified in this multi-institutional dataset with BAT and abdominal CT imaging, and 726 were included. Of those, 59 underwent surgical intervention (8.8%). Univariate analysis of association between the studied factors and need for surgical management showed that the presence of TLF (p < 0.01), APT (p < 0.01), FF (p < 0.01), and SOI (p < 0.01) were significantly associated. A predictive model was created using the 5 factors resulting in an area under the curve (AUC) of 0.80. For the motor vehicle collisions (MVC) group, only FF, SOI, and TLF are significantly associated with the need for surgical intervention. The AUC for the MVC group was 0.87. A clinical and radiologic prediction rule was validated using a large multi-institutional dataset of pediatric BAT patients, demonstrating a high degree of accuracy in identifying children who underwent surgery. FF, SOI, and TLF are the most important factors associated with the need for surgical intervention. Level III.

Predictors of Intrathoracic Injury after Blunt Torso Trauma in Children Presenting to an Emergency Department as Trauma Activations

Predictive Model for Operative Intervention after Blunt Abdominal Trauma in Children with Equivocal CT Findings: A Pilot Study

Blunt abdominal trauma in childhood contributes significantly to both morbidity and mortality. Selective non-operative management of blunt abdominal trauma in children depends on both diagnostic and clinical factors. Computed tomography (CT) scanning is widely used to facilitate better management. Increased availability of CT may, however, result in its overuse in the management of blunt abdominal trauma in children, which carries significant radiation exposure risks. To evaluate the use and value of CT scanning in the overall management and outcome of blunt abdominal trauma in children in the Tygerberg Academic Hospital trauma unit, Parow, Cape Town, South Africa, before and after improved access to CT as a result of installation of a new rapid CT scanner in the trauma management area (previously the scanner had been 4 floors away). Patients aged 0 - 13 years who were referred with blunt abdominal trauma due to vehicle-related accidents before the introduction of the new CT scanner (group 1, n=66, November 2003 - March 2009) were compared with those seen in the 1-year period after the scanner was installed (group 2, n=37, April 2009 - April 2010). Details of clinical presentation, imaging results and their influence on management were retrospectively reviewed. A follow-up group was evaluated after stricter criteria for abdominal CT scanning (viz. prior evaluation by paediatric surgical personnel) were introduced (group 3, n=14, November 2011 - May 2012) to evaluate the impact of this clinical screening on the rate of negative scans. There were 66 patients in group 1 and 37 in group 2. An apparent increase in CT use with increased availability was accompanied by a marked increase in negative CT scans (38.9% compared with 6.2%; p<0.006). Despite a slightly higher prevalence of associated injuries in group 2, as well as a slightly longer length of hospital stay, there was a similar prevalence of intra-abdominal injuries detected in positive scans in the two groups. In addition, rates of small-bowel perforation in the two groups were similar. The rate of negative scans in group 3 was 46.2% (6/13), but all except one of these patients had a severe brain injury preventing adequate clinical evaluation of intra-abdominal injury. CT scanning for blunt abdominal trauma in children is essential in the presence of appropriate clinical indications. Ease of access probably increases availability, but the rate of negative scans may increase. Management guidelines should be in place to direct CT scanning to cases in which clinical examination and/or other modalities indicate a likelihood of intra-abdominal injury. The principle of 'as low (radiation) dose as reasonably achievable' (ALARA) should be adhered to because of the increased radiation exposure risks in children.

Duodenal rupture with avulsion of the papilla of Vater is an uncommon injury due to blunt abdominal trauma in children. This report describes a 9-year-old boy who sustained this injury and was treated successfully two days delayed by a Roux-en-Y choledocho-pancreaticojejunostomy and temporary implantation of a zipper for abdominal wall closure. The rarity of this complex injury and its initial presentation as a posttraumatic pancreatitis warrant its description. A review of the literature, modes of diagnosis and surgical technique for repair are described.

Localized low-energy abdominal trauma is very frequent in the pediatric population. The findings of several studies have shown that ultrasonography (US) can represent a useful and cost-effective tool in the evaluation of blunt abdominal trauma both in adults and children. However, many parenchymal injuries are not correctly visualized at baseline US examination. The introduction of specific US contrast agents contrast-enhanced ultrasound (CEUS) has enabled a better identification of traumatic organ injuries. The correct use of CEUS could therefore identify and select the children who need further diagnostic investigation computed tomography (CT), avoiding unnecessary radiation and iodinated contrast medium exposure. The purpose of our study was to assess the sensibility and feasibility of CEUS in the assessment of low-energy abdominal trauma compared to baseline US in pediatric patients, using contrast-enhanced MDCT as the reference standard. We retrospectively reviewed 73 children (51 M and 22 F; mean age 8.7 ± 2.8 years) who presented in our Emergency Department between October 2012 and October 2013, with history of minor abdominal trauma according to the Abbreviated Injury Scale and who underwent US, CEUS, and CE-MDCT. Inclusion criteria were: male or female, aged 0-16, hemodynamically stable patients with a history of minor blunt abdominal trauma. Exclusion criteria were adulthood, hemodynamical instability, history of major trauma. Sensitivity, specificity, PPV, NPV, and accuracy were determined for US and CEUS compared to MDCT. 6/73 patients were negative at US, CEUS, and MDCT for the presence of organ injuries. In the remaining 67 patients, US depicted 26/67 parenchymal lesions. CEUS identified 67/67 patients (67/67) with parenchymal lesions: 21 lesions of the liver (28.8 %), 26 lesions of the spleen (35.6 %), 7 lesions of right kidney (9.6 %), 13 lesions of left kidney. MDCT confirmed all parenchymal lesions (67/67). Thus, the diagnostic performance of CEUS was better than that of US, as sensitivity, specificity, PPV, NPV, and accuracy were 100, 100, 100, 100, and 100 % for CEUS and 38.8, 100, 100, 12.8, and 44 % for US. In some patients CEUS identified also prognostic factors as parenchymal active bleeding in 8 cases, partial devascularization in 1 case; no cases of vascular bleeding, no cases of urinoma. MDCT confirmed all parenchymal lesions. Parenchymal active bleeding was identified in 16 cases, vascular bleeding in 2 cases, urinoma in 2 cases, partial devascularization in 1 case. CEUS is more sensitive and accurate than baseline US and almost as sensitive as CT in the identification and characterization of solid organs lesions in blunt abdominal trauma. CT is more sensitive and accurate than CEUS in identifying prognostic indicators, as active bleeding and urinoma. CEUS should be considered as a useful tool in the assessment and monitoring of blunt abdominal trauma in children.