Chest trauma

Chest Injuries in Childhood

DON K. NAKAYAMA, M.D., MAX L. RAMENOFSKY, M.D., and MARC 1. ROWE, M.D.

Differences in anatomy and mechanisms of injury are believed to contribute to the unique response of children to thoracic trauma. To characterize the scope and consequences of childhood chest injury, we reviewed the records of 105 children (ages 1 month to 17 years, mean 7.6 years) with chestinjuries admitted to a level I pediatric trauma center from 1981 to 1988. Nearly all injuries (97.1%) were due to blunt trauma, and more than 50% were traffic related. Rib fractures, commonly multiple, and pulmonary contusions occurred with nearly equal frequency (49.5% and 53.3%, respectively), followed by pneumothorax (37.1%) and hemothorax (13.3%). One fourth of all pneumothoraces were undertension. Significant intrathoracic injuries occurred without rib fractures in 52% of cases with blunt trauma. Associated head, abdominal, and orthopedic injuries were present in 68.6% of children reviewed. One in five received endotracheal intubation and ventilatory support for 1 to 109 days. Presence or absence of head injury neither increased the need for respiratory support (29.4% vs. 17.2%,respectively; p = 0.24) nor affected the duration of support for those who were ventilated (6.8 ± 8.9 days vs. 3.3 ± 2.6 days, excluding one ventilatordependent head-injured patient and five early deaths). The presence of associated injuries, intubation, and pneumothorax or hemothorax all resulted in significantly longer hospitalizations and more severe injury as measured by Injury Severity Score(ISS). Age, rib fracture, and contusion had no effect. Rarely encountered were ruptured diaphragm (2 cases), transection of the aorta (1), major tracheobronchial tears (3), flail chest (1), and cardiac contusion (2). Only two of the three children with penetrating injuries and three of the 83 (3.6%) with blunt injuries underwent chest operations. Six children (7%) died, one from a penetrating injuryand five from blunt mechanisms. Chest Abbreviated Injury Scale (AIS) and ISS correlated significantly with mortality; age and head AIS did not. Rib fractures, lung contusions, and associated head, abdominal, and skeletal injuries are common because of the predominance of blunt-injury mechanisms. Nearly one half of chest injuries occurred without rib fractures. The need for ventilatory support isuncommon; when required, its duration is
Supported in part by grants from the Claude Worthington Benedum Foundation and the Health Research and Services Foundation, Pittsburgh Pennsylvania. Correspondence and reprint requests to: Don K. Nakayama, M.D., One Children's Place, 3705 Fifth Ave. at DeSoto St., Pittsburgh, PA 15213-2583. Accepted for publication: March 17, 1989.

From the BenedumPediatric Trauma Program, the Department of Pediatric Surgery, the Children's Hospital of Pittsburgh, and the Department of Surgery, the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

generally brief. Aortic transection, flail chest, and penetrating injuries more frequently encountered in adults and are uncommon in children. Thoracotomy generally is not required. Theseobservations arise from (1) the compliant thoracic structures of children; (2) the fact that children, as passengers or pedestrians in motor vehicle crashes, are not subjected to the same highspeed chest impact to which adult drivers are subject; and (3) the fact that children usually are not exposed to gunshot and stab wounds that are so common in adult urban violence.
T n HE EVALUATION AND treatment ofthoracic trauma is a central feature of the early assessment

and management of the injured child because chest injury may lead to tissue hypoxia.' Difficulties may arise when managing thoracic injuries in children. They rarely occur alone and are often a component of major multisystem injuries. Differences in anatomy and mechanisms of injury distinguish childhood injuries from those of...