Chest trauma

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS clinical disclaimer

Aim

To guide Emergency Department (ED) staff with the assessment and management of children with major chest trauma. 

Key Points^1,2

• Thoracic injuries in children are usually due to blunt trauma.
• The most common injuries are rib fractures, pulmonary contusions, pneumothoraces and haemothoraces.
• These can usually be managed by a combination of adequate oxygenation, analgesia, IV fluid/blood and chest drain.
• Surgical intervention is indicated in cases of massive haemothorax, cardiac tamponade, major airway and oesophageal injury, aortic and diaphragmatic injuries.
• ED thoracotomy is an extremely rare procedure, principally indicated in cases of penetrating chest trauma and an arrest or pre-arrest presentation to a tertiary hospital.

Initial stabilization of child with chest trauma

Primary survey (see guideline Trauma - Serious injury)

• A – Airway – ensure patency, exclude airway injury. Maintain C-spine precautions.
• B – Breathing – provide high flow oxygen, check position of trachea, percuss for dullness, auscultate for equal air entry, exclude tension pneumothorax, examine for chest wall tenderness, flail segments or wounds.
• C - Circulation - IV access and fluid resuscitation.

Analgesia should be initiated early and titrated to effect.

Investigations

At Resuscitation: portable chest X-Ray (CXR) - unless signs of tension pneumothorax 

Once stabilised: thoracic computerised tomography (CT) scan if suspected major injury.

Indications for mechanical ventilation following chest trauma

• Ongoing respiratory distress/failure despite:
  • Optimisation of oxygen delivery.
  • Adequate analgesia.
  • Chest drain insertion (when indicated).
  • Closure of any open chest wounds.

Severe haemodynamic instability

• Other bleeding source
• Tension pneumothorax
• Massive haemothorax
• Cardiac tamponade
• Pericardial injury
• Tracheobronchial or mediastinal injury
• Diaphragmatic injury.

Indications for operative intervention in chest trauma

Massive haemothorax, great vessel injury, pericardial tamponade, tracheobronchial injuries, oesophageal injury, diaphragmatic lacerations, open pneumothorax with major chest wall defect, penetrating chest trauma that crosses the mediastinum.

Specific injuries^1,2,3

Rib fractures

• In children, rib fractures may be a marker of potential severe underlying injuries, especially if multiple or 1st rib fractures.
• Flail chest injuries are rare in children.
• Rib fractures in 0 to 3 year old - consider non accidental injury.

Management

• Analgesia
• Oxygen supplementation in severe cases.

Pulmonary Contusion

• Can occur in the absence of rib fractures or other external signs
• CXR: increased pulmonary opacity, changes may evolve over time
• CT scan: may reveal contusion not evident on the initial plain films.

Management

• Oxygen supplementation
• May require non-invasive or invasive ventilation
• Analgesia as indicated
• Avoid excessive intravenous fluids.

Pneumothorax

• Clinical signs: possible spectrum from nothing, to decreased air entry (AE) and hyper resonance 
• CXR: a small pneumothorax may not be visible. Suspect if: increased radiolucency, deep sulcus sign.

Management

• Chest drain management - PCH Clinical Practice Manual (WA Health only)
• Intercostal catheter - ED Guideline

Tension Pneumothorax

• Clinical diagnosis, treatment should precede radiology in clear-cut unstable cases.
• Signs: decreased air entry, hyper resonance, hyperexpansion, decreased movement of the affected side, tracheal deviation, tachycardia, low or falling O₂ saturations. Hypotension is a late sign.

Management

• Needle decompression: 16G cannula in 2nd intercostal space in mid-clavicular line, then formal intercostal tube.
• Alternatively, or if needle decompression not successful, perform finger thoracostomy in 4th or 5th intercostal space in anterior axillary line and follow by formal intercostal catheter.

Open pneumothorax

Management

• Initially cover wound with 3 sided occlusive dressing (thus creating a one-way valve)
• Formal chest drain placed away from wound

Pulmonary Lacerations

• Penetrating injuries or associated with rib fractures
• Cause haemothorax or pneumothorax, and rarely, air embolism

Haemothorax

• Each hemithorax can hold up to 40% of a child’s blood volume.
• Signs: reduced air entry and dullness to percussion. Signs of tension pneumothorax may co-exist.

Management

• Chest drain management - PCH Clinical Practice Manual (WA Health only)
• Intercostal catheter - ED Guideline
• Intravascular volume resuscitation (may require critical bleeding protocol / massive transfusion). Refer to Critical Bleeding Protocol and ROTEM Algorithm (Transfusion Medicine Protocols)

ED Thoracotomy

This is rarely indicated and only likely to be useful in a paediatric tertiary centre where the child can subsequently go directly to theatre with cardio-thoracic surgical facilities.

The only situation may be in the child with penetrating chest trauma with loss of vital signs shortly before arrival in the ED or during ED resuscitation (at a tertiary centre).

Indications for thoracotomy

• Initial drainage >15 mL/kg of blood via the chest tube
• Continued bleeding > 1-2 mL/kg/hour
• Increasing bleeding
• Significant residual haemothorax post drainage.

Tracheobronchial injuries

• Uncommon

Signs

Subcutaneous emphysema, tension pneumothorax, haemoptysis, ongoing air leak and failure of lung expansion on CXR.

Management

• Cardio-thoracic surgical consultation
• Consider second chest tube.

Mediastinal injury

• Most are rapidly fatal at the scene

Diagnosis

• Suspicion based on mechanism of injury, physical signs (often absent) and CXR findings

CXR signs of aortic injury

• Widened mediastinum (mediastinum to chest ratio > 0.25). Loss or abnormal contour of aortic knob
• Depression of left mainstem bronchus
• Deviation of the trachea to the right
• Deviation of the oesophagus (nasogastric (NG) or orogastric (OG) tube) to the right
• Left pleural cap
• Left haemothorax
• Upper rib fractures

Imaging

• CT angiography, aortogram or transoesophageal echocardiography.

Management

Confirmed cases require urgent surgical referral.

Cardiac injuries

Uncommon: Pericardial tamponade, myocardial contusion

Signs

Tachycardia, elevation of jugular vein pressure, hypotension, arrest with pulseless electrical activity.

Investigations

Endorsed by:	Nurse Co-director, Surgical Services	Date:	Apr 2022
		Review date:	Sep 2025

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