Trauma and the paediatric lung

Factors Predicting Lung Contusions in Critically Ill Trauma Children: A Multivariate Analysis of 330 Cases

PURPOSE

The aim of the study was to identify factors predicting lung contusion in trauma children.

METHODS

Retrospective study conducted for a period of 8 years (January 01, 2005-December 31, 2012) in a medical surgical intensive care unit. All trauma patients younger than 15 years were included. Two groups were compared: those with lung contusions (C+ group) and those without lung contusions (C- group).

RESULTS

We included 330 patients. The mean (SD) age was 7.6 (4.3) years. Chest injury was diagnosed in 70 patients (21.2%). All our patients needed mechanical ventilation. Lung contusions were diagnosed in 43 patients (13% of all patients and 61.4% of patients with chest trauma). In multivariate analysis, independent factors predicting lung contusion were road traffic accident (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.2-8.6; P = 0.019), increased Pediatric Risk of Mortality (PRISM) score (OR, 1.1; 95% CI, 1.1-1.2; P = 0.017), hepatic contusion (OR, 4.8; 95% CI, 1.3-17.1; P = 0.017), and pelvic ring fracture (OR, 3.5; 95% CI, 1.1-10.5; P = 0.026). Death occurred in 46 patients (13.9%). Intensive care unit mortality was significantly higher in the C+ group (OR, 2.5; 95% CI, 1.2-5.4; P = 0.021). However, mortality was not different between the 2 groups after adjusting for PRISM score (OR, 1.2; 95% CI, 0.5-2.9; P = 0.752) or after adjusting for Injury Severity Score (OR, 0.7; 95% CI, 0.3-2.1; P = 0.565).

CONCLUSIONS

Lung contusion is common in critically ill children with chest trauma. The diagnosis should be considered in patients with road traffic accident, increased PRISM score, hepatic contusion, and pelvic ring fracture.

No breakpoint for mortality in pediatric rib fractures

BACKGROUND

Rib fracture number correlates with mortality in adult trauma patients, sharply rising above six fractured ribs. Because of the pliability of younger ribs, pediatric ribs are believed to require more energy to fracture. We hypothesized this will result in a different rib fracture-associated pediatric mortality rate.

METHODS

We queried the National Trauma Data Bank (American College of Surgeons, Chicago, Illinois) for patients younger than 21 years with and without rib fractures (2002-2009), abstracting the number of rib fractures, diagnoses, procedures, and outcomes. Univariable and multivariable analyses were performed with logistic regression to adjust for age and concomitant injury.

RESULTS

We identified 729,240 pediatric patients, 19,442 with rib fractures. Mortality doubled from 1.79% without rib fracture to 5.81% for one rib fracture and then nearly linearly increased to 8.23% for seven fractures unlike the pattern in adults. This pattern persisted irrespective of the age group evaluated. Ventilator days also increased with increasing number of rib fractures. Adjusted odds of mortality increased up to six rib fractures for all age groups. Penetrating injury, concomitant injury, and hemothorax all predicted mortality on multivariable analysis. More than two rib fractures also predicted chest tube placement (odds ratio [OR], thoracostomy 11.89 (11.37-12.44), thoracotomy 5.89 (5.17-6.84), thoracoscopy (6.28-12.03), laparotomy 2.68 (2.49-2.89).

CONCLUSION

Mortality increased nearly linearly for increasing numbers of pediatric rib fractures without an inflection. Odds of mortality increases with each additional rib fractured in all pediatric age groups.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Pediatric Blunt Thoracic Trauma

Thoracic injury in children deserves special attention because, although it accounts for less than 10% of traumatic injuries in children, there is a significant associated morbidity and mortality. This review discusses the anatomic and physiologic factors resulting in such injury severity with blunt thoracic trauma in children. Specific organ injuries, including most common chest wall injuries, hemo- and pneumothoraces, and pulmonary parenchymal injuries, are discussed, encompassing epidemiology, presentation, diagnosis, and management. Rare injuries including tracheobronchial tree injuries, cardiovascular injuries, esophageal injuries, and diaphragmatic injuries are also briefly discussed.

Co-existence of posttraumatic empyema thoracis and lung abscess in a child after blunt chest trauma: a case report

Posttraumatic empyema is a rare complication of trauma with an incidence of 1.6-2.4% in trauma patients. However, it is rarely reported in children. We report the case of a 15-year-old boy who was involved in a traffic accident and diagnosed with a pulmonary contusion at a local hospital. Fourteen days after the accident, posttraumatic empyema thoracis and lung abscess developed with clinical presentations of fever, productive cough and right chest pain. He was successfully treated with computed tomography-guided catheter drainage and intravenous cefotaxime. We emphasize that posttraumatic empyema thoracis and lung abscess are very rare in children, and careful follow-up for posttraumatic lung contusion is essential. Image-guided catheter drainage can be an adjunctive tool for treating selected patients, although most complicated cases of posttraumatic empyema thoracis require decortication therapy.

Paediatric chest trauma (part 1) — Initial Lethal Injuries

Chest trauma is the second greatest cause of mortality from trauma, a leading cause of death in children over the age of one. Prompt diagnosis can be difficult as the underlying thoracic injuries are often disproportionately severe compared to the visible surface injury and symptoms may not appear for several hours. Diagnosis is easily underestimated, delayed or missed. This is a two part article reviewing paediatric chest trauma and its current management. The injuries are usefully classified into six lethal injuries that need excluding in the primary survey and six hidden injuries that must be considered in the secondary survey. The first article reviews paediatric anatomy and biomechanics, and mechanisms of injury with a view to improving the awareness and understanding of the unique response of children to thoracic trauma. This is followed by an in depth review of each of the six lethal injuries. The subsequent article reviews the six hidden injuries as well as the role of chest trauma in non-accidental injury.

Paediatric chest trauma (part 2) — Hidden Injuries

Chest trauma is the second greatest cause of mortality from trauma, a leading cause of death in children over the age of one. Prompt diagnosis can be difficult as the underlying thoracic injuries are often disproportionately severe compared to the visible surface injury and symptoms may not appear for several hours. Diagnosis are easily underestimated, delayed or missed. This is the second of a 2 part article reviewing Paediatric chest trauma and its current management. The injuries are usefully classified into 6 lethal injuries that need excluding in the primary survey and 6 hidden injuries that must be considered in the secondary survey. The 6 lethal injuries are covered in the first part of this article along with biomechanics and mechanisms of injury. This article looks in depth at the 6 hidden injuries, along with a review of chest trauma in non-accidental injury.

The lung and pediatric trauma

Thoracic trauma is relatively frequent in children and causes considerable mortality. This is mainly due to the multiorganic nature of the trauma. The lung is more often affected even in the absence of rib fractures because of the considerable pliability of the chest wall that allows direct transfer of energy to this organ. Injuries to the heart, the aorta, the esophagus, and the diaphragm are rare. Lung contusion and laceration cause parenchymal hemorrhage and consolidation sometimes accompanied by pneumothorax and/or hemothorax. Tracheobronchial disruption is rare but life-threatening. Most traumatic lung injuries may be treated with rest, respiratory support, and eventually intercostal drainage. Large hemorrhage may require thoracotomy, and persistent pneumothorax (indicative of tracheobronchial disruption) may require intubation with fiberoptic bronchoscopic assistance and eventually reparative or ablative surgery. Adult respiratory distress syndrome is very rarely seen in children with thoracic trauma, but it remains highly lethal.

Lung contusion from focal low-moderate chest trauma

Apparently minor chest trauma may result in localized pulmonary contusion. Complications of the contusion, particularly infection, may be delayed. The association between the infection and initial injury may not be appreciated due to the time frame between the injury and clinical presentation. We report two cases of low-moderate impact pulmonary trauma resulting in focal pulmonary contusion, complicated by infection.