Trauma related pediatric thoracic injury admitted to trauma hospitals carries a mortality rate of five percent. This refers to injuries to the chest wall and any structure within. Pediatric trauma surgeons understand the anatomy of the growing child and how injury patterns change with age. Unique to pediatric trauma is the effect of the growing skeleton that makes the thoracic spine and rib cage exceptionally compressible so that in the case of a high velocity blunt trauma to the thorax, the front of the rib cage can meet the back of the rib cage and then recoil without fracturing the spine or the ribs. In essence the force is directly exerted to the lung causing significant pulmonary (lung) contusions without rib fractures. Because of this mechanism, pulmonary contusions in children are the most common thoracic injury that is responsible for admissions into trauma centers.
Pediatric and adult pulmonary contusions are similar in that both will cause acute inflammation of the lung tissue that produces inflammatory fluid that leaks from the lung cells into the smallest airways of the lung interfering with gas exchange, and eventually causing pulmonary edema. Children, however, are more prone to rapid respiratory failure and the need for emergent mechanical ventilation than adults because of two anatomic differences. First, children have a smaller residual capacity than adults, which refers to the lung volume that is available to oxygenate the blood in times of illness or exercise. Second, less oxygen is delivered with an inspiratory breath in a child than in adults since the diameter of the trachea is smaller when compared to the relative size of the lungs. Therefore, in the setting of a pulmonary contusion, children are more prone to rapid respiratory failure and the need for emergent mechanical ventilation.
Studies indicate that one in four pediatric admissions with a pulmonary contusion will require mechanical ventilator support for approximately five days. This compares to forty percent of adult patients with pulmonary contusions will require ventilator support for an average of ten days. Adults with pulmonary contusions require significantly more intensive level medical care because they often have a flail chest that reduces or prevents lung expansion with inspiration. Children on the other hand, do not have the rib fractures that cause a flail chest and likely this accounts for the differences in incidence and time on the ventilator. Chest x-rays are generally diagnostic of pulmonary contusions on admission to the hospital. CT scans should be ordered to rule out associated injuries in the thorax. CT scans are useful as well since they can quantitate the percent of the lungs that is damaged and studies indicate that if more than 28% of the lung is involved with a contusion mechanical ventilation is likely going to be needed while those with less than 18% are much less likely to require mechanical ventilation.
Children with pulmonary contusions who require mechanical ventilation will generally require this within the first few hours after trauma. Therefore, if there is a significant percentage of the lung involved or associated injuries in the thorax that places the child at risk, these children should be observed in an Intensive Care Unit and treated aggressively with fluid restriction, pain control, early mobilization, and incentive spirometry to prevent lung collapse and pulmonary edema.
Approximately twenty percent of children with a pulmonary contusion develop pneumonia and ten percent of those whom require mechanical ventilation may develop ‘acute respiratory distress syndrome’ (ARDS). Fortunately, studies indicate there will be little to no disability in children who suffer pulmonary contusions from respiratory impairments. In fact, a small study followed children who had ARDS over 12 years and this study indicated that despite the prior history of ARDS the children’s lungs recover by various mechanisms and have normal pulmonary function tests overtime.
Fortunately, pulmonary contusions are rarely the cause of death in children. Mortality from an isolated thoracic injury is more likely due to other diagnoses such as a massive hemothorax, acute airway obstruction, or a cardiac contusion. The morbidity and mortality in children with pulmonary contusions are most related to the concomitant injuries that are associated with the high velocity blunt injuries related to motor vehicle accidents. Mortality rates increase to twenty-five percent in the case where thoracic injuries are accompanied by head or abdominal injury and jumps to forty percent in the case where thoracic injuries are accompanied by head and abdominal injuries.
Academic Physician Life Care Planners are in the unique position to understand the individualized needs of a polytrauma patient. Evidence of a pulmonary contusion alone is direct evidence of a significant acceleration and deceleration type injury and a concomitant traumatic brain injury. These children must be followed over time with neuropsychological assessments since they are at risk for various educational, cognitive-communicative, and behavioral challenges going forward.
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