Trauma is the leading cause of childhood morbidity and mortality in the United States, accounting for greater than 7.5 million emergency department visits annually. Chest trauma is the second leading cause of mortality in pediatric trauma patients and is often encountered in the setting of multisystem trauma, usually caused by high-energy impact incidents such as motor vehicle collisions. Blunt-chest injuries account for greater than 80% of pediatric chest trauma and often require a longer hospital length of stay compared with penetrating chest injuries.
The following anatomic and pathophysiologic features of children differentiate chest trauma in children from those in adults:
Increased chest wall compliancy due to pliability of cartilage allows the chest to absorb energy and dissipate it to the internal organs without necessarily resulting in rib fractures.
Increased incidence of traumatic asphyxia and commotio cordis because of increased chest wall compliancy.
A larger blood volume relative to body weight can result in a higher incidence of hypovolemia and shock despite smaller amounts of blood loss.
Relatively smaller body mass index results in greater energy of forces dispersed over a smaller area.
A more mobile mediastinum increases the incidence of intrathoracic injuries such as pneumothorax, hemothorax, which can lead to cardiovascular compromise.
IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS
ESTABLISH AIRWAY, BREATHING, & CIRCULATION
Priorities for trauma patients are to establish a definitive airway, manage breathing and then circulation. Causes of airway compromise, which can occur at any level from the pharynx to the trachea, as well as disorders of ventilation/oxygenation in the pediatric chest trauma patient include
Direct interruption or injury of the respiratory tract
Impairment in gas exchange from hypoventilation secondary to pain or neurological injury
Injuries to the chest wall, pleura, and lung parenchyma (atelectasis, contusions, hemothorax, or pneumothorax)
Adequate pain control is important to ensure maximal comfort, resulting in improved chest wall movement and expansion to optimize oxygen exchange and ventilation. Parenteral narcotics (morphine, fentanyl) are used for this goal, and may require multiple doses.
IMMEDIATE MANAGEMENT OF LIFE-THREATENING INJURIES
Life-threatening injuries should be identified on the primary survey, and require immediate action without definitive diagnostic testing, as these measures are often lifesaving.
Tension pneumothorax occurs when air accumulates in the intrapleural space (Figure 25–1). It is often seen with injury to the lung parenchyma or bronchus, as air flows unidirectionally into the pleural space. Air flows in during inspiration and is unable to escape during expiration. The accumulated air can lead to lung collapse on the affected side and shift of the mediastinal contents to the contralateral side. A large tension pneumothorax can decrease venous return to the heart, with subsequent cardiovascular collapse.