I struggled to find PEM resources for my CT3 year, despite the variety of excellent resources out there. I hope this website will help point you in the right direction. I'm not a PEM expert, but am following the guidance CEM have issued (in the form of a syllabus) to put together this page. This page is not endorsed by CEM, and any mistakes are mine.

Please comment with corrections, additions and further suggestions.

All the information here is collected from the internet, and it might be out of date or inaccurate, so please use your judgement and adhere to your hospital's protocols. If you do notice any errors or omissions please comment so we can put them right!

To navigate, decide whether you want to start with a PMP or a PAP. You can then select which PMP or PAP you want to look at. You will then be taken to the summary page for that PMP, with links expanded topic collections. If you know what topic you want to look at already, click on the link on the right hand side.

Wednesday, 21 August 2013

Chest Trauma in Children

"Know the likely injuries through different age groups including pulmonary contusion and flail chest"

Isolated significant chest trauma is rare in paediatrics, but is still the second highest cause of trauma related death in paediatrics (although whether the death was caused by the chest or by other injuries is difficult to tell). There is an excellent handbook from the Royal Children's Hospital in Melbourne which probably  tells you everything you need to know. There is a 2008 review in "Trauma" and a really nice overview presentation here.

Most chest injuries are caused by blunt trauma and  RTCs, and are normally associated with injuries elsewhere. The anatomy is similar to adults (excellent podcast here), but children are different - especially if they are younger:
  • Smaller
    • Traumatic forces distributed over a smaller mass
    • Smaller thoracic volume
    • Compact organs
  • Increased chest wall compliance
    • Ribs unlikely to break
    • Internal injuries likely with minimal external signs
  • Compensatory mechanisms may mask hypovolaemia
  • Mobile mediastinum
    • Airway injuries rare
    • Mediastinal shift may cause problems
  • Aerophagia is a common response in children
    • Causes reflex ileus
    • Leads to gastric dilation 

As in adults, there are six life threatening chest injuries to remember, remembered by the mnemonic "ATOM FC". These should be identified on the primary survey:
 - Airway Obstruction
 - Tension Pneumothorax
 - Open pneumothorax
 - Massive haemothorax
 - Flail chest
 - Cardiac Tamponade

The Trauma journal review also reports there are six "hidden" but life threatening injuries:
-Cardiac contusions
-Aortic disruption
-Tracheobronchial disruption
-Oesophageal disruption
-Diaphragmatic tear
-Pulmonary contusion

We're hopefully pretty good at identifying the life threatening injuries. Often we suspect the "hidden" injuries. But how do we make the final diagnosis, especially as we know that we don't want to do unnecessary CTs on children.

This short presentation introduces some clinical decision rules to help you decide who needs chest imaging. Using a paper from the Annals of Emergency Medicine (which I can't access as it doesn't support Athens or Institutional Access) they suggest we only do a CXR in trauma if:
  • Low BP/Increased RR
  • Abnormal chest exam
  • GCS<15
  • Femur fracture
After trauma, most children I've seen have got an increased respiratory rate, so making sure we do a CXR for everyone doesn't seem unreasonable.  What about CT?

Pediatric Radiography have looked at how CT changes our management of paediatric patients. Again, I can only access the abstract:
235 children had a CXR and a CT done. In 1/3 CXR abnormal, and in 2/3 CT was abnormal.
Out of all the children, <5% got any chest procedure

<10% of kids with pneumothorax on CT got a chest tube
91% of CT findings were within 1cm of dome of liver --> visible on CT abdomen.

So this study would suggest that routinely doing a CT chest on all children may be unnecessary. Given that most of our treatment for chest injury is analgesia, and supporting ventilation, CT rarely changes management. Not all pneumothoraces are treated with a chest drain.
I'm not sure I'd be ready to chance hospital policy yet, but it is certainly something to think about! 

Lung Contusion
This is the most common chest injury in children, and can occur without chest wall injury.

-  Hypoxia
-  Consolidation on CXR (in 90% on initial CXR)
        - May be irregular and not conform to lobes
- CT scans pick up more scans
       - 38% of dogs experiencing blunt trauma had consolidation on CXR, compared to 100% on CTs

- Oxygen
- Analgesia
- Pulmonary toilet
- Ventilatory Support

Flail Chest
Flail chest is very rare, but can happen. The paraxodical chest movement caused by two or more rib fractures contributes towards respiratory distress. These often occur with pulmonary contusions. There is a very good explanation with some excellent pictures here.

- Place the patient injury side downwards
- Intensive respiratory support
- Analgesia

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