1

PEDIATRICPEDIATRICPEDIATRIC PEDIATRIC CHEST TRAUMACHEST TRAUMA

Children are not small adultsChildren are not small adultsRole of imagingRole of imagingSpectrum of injurySpectrum of injury

2

Children are notChildren are notChildren are not Children are not small adultssmall adults

Children are Not Small AdultsChildren are Not Small AdultsAnatomic considerationsAnatomic considerations

Pliable bony & cartilagenous structuresPliable bony & cartilagenous structures-- Significant thoracic injury w/out bony injurySignificant thoracic injury w/out bony injuryGreater vessel elasticityGreater vessel elasticity-- Aortic & great vessel injury rareAortic & great vessel injury rareAortic & great vessel injury rareAortic & great vessel injury rare

3

Children are Not Small AdultsChildren are Not Small AdultsPhysiologic considerationsPhysiologic considerations

Smaller blood vessels & enhanced Smaller blood vessels & enhanced vasoconstrictionvasoconstriction-- Bleeding often stops spontaneouslyBleeding often stops spontaneouslySmaller circulating blood volumeSmaller circulating blood volume-- Greater physiologic derangement w/ injuryGreater physiologic derangement w/ injury

Children are Not Small AdultsChildren are Not Small AdultsPhysiologic considerationsPhysiologic considerations

Presence & severity of chest injury Presence & severity of chest injury strongly impacts outcomestrongly impacts outcome

Lower mean trauma scoreLower mean trauma scoreIncreased mortalityIncreased mortality

Sivit. Radiology 1989;171:815Sivit. Radiology 1989;171:815

4

Children are Not Small AdultsChildren are Not Small AdultsAnatomic considerationsAnatomic considerations

Smaller sizeSmaller sizeSmaller sizeSmaller size-- Smaller FOV & decreased contrast volumeSmaller FOV & decreased contrast volume

IV contrastIV contrast-- 11--2 cc/kg; max 120 cc 2 cc/kg; max 120 cc -- inj vol/60 secinj vol/60 sec

Increased sensitivity to radiationIncreased sensitivity to radiation-- Use low tube current & breast shieldingUse low tube current & breast shielding

Role of imagingRole of imaging

5

Thoracic TraumaThoracic Trauma

RadiographyRadiographyRadiographyRadiographyIdentify lifeIdentify life--threatening injurythreatening injuryAssess gasAssess gas--exchange capability exchange capability Localize tubes & Localize tubes & catheterscatheters

Radiography Radiography -- LimitationsLimitations

Underestimates or misses > 1/3 injuriesUnderestimates or misses > 1/3 injuriesLacks specificity for mediastinal injuryLacks specificity for mediastinal injuryImprecise localization of thoracotomy Imprecise localization of thoracotomy tubestubes

6

Initial supine exam Repeat erect exam

7

CTCT

Improved injury detectionImproved injury detectionImproved injury detection Improved injury detection & quantification & quantification Greater specificity for Greater specificity for mediastinal bleedmediastinal bleedPrecise localization ofPrecise localization ofPrecise localization of Precise localization of thoracostomy tubesthoracostomy tubes

CT CT -- LimitationsLimitations

Lacks specificity for tracheal & mainLacks specificity for tracheal & mainLacks specificity for tracheal & main Lacks specificity for tracheal & main bronchial injurybronchial injuryLacks specificity for esophageal injuryLacks specificity for esophageal injury

8

Spectrum of injurySpectrum of injury

Chest wall injuryChest wall injury

May have significant intraMay have significant intra--thoracic injury thoracic injury w/out bony injuryw/out bony injuryDisplaced rib fractures Displaced rib fractures maymay result in injuryresult in injuryInfant rib fractures specific for abuseInfant rib fractures specific for abuseInfant rib fractures specific for abuseInfant rib fractures specific for abuseMultiple fractures marker for severe injuryMultiple fractures marker for severe injury

9

Rib fractures in Child AbuseRib fractures in Child Abuse

S fS fSqueezing force Squeezing force during shaking during shaking Involve posterior & Involve posterior & lateral arcs lateral arcs Frequently multipleFrequently multipleFrequently multiple Frequently multiple and bilateraland bilateral

10

Multiple rib fracturesMultiple rib fractures

Multiple fractures result fromMultiple fractures result fromMultiple fractures result from Multiple fractures result from great deal of kinetic energy great deal of kinetic energy associated with severe injuryassociated with severe injuryAssociated with increased Associated with increased morbidity & mortalitymorbidity & mortality

Garcia. J Trauma 1990;30:695Garcia. J Trauma 1990;30:695

11

Parenchymal injuryParenchymal injury

Spectrum of injurySpectrum of injuryDirect compressionDirect compressionContrecoup compressionContrecoup compressionShearing forcesShearing forcesShearing forcesShearing forcesLaceration by fractured ribsLaceration by fractured ribs

ContusionContusionAlveolar & interstitial Alveolar & interstitial hemorrhage & edemahemorrhage & edemaFocal or multifocal opacitiesFocal or multifocal opacitiesPosterior > anteriorPosterior > anteriorSubpleural sparingSubpleural sparing

12

13

LacerationLaceration

Torn alveoli or bronchiolesTorn alveoli or bronchiolesParenchymal air cavitiesParenchymal air cavitiesMay be surrounded by hemmorhageMay be surrounded by hemmorhageFavorable outcome w/ medical mgmtFavorable outcome w/ medical mgmt

14

15

Initial exam F/U 3 days later

16

Initial exam

+3d +10d

Thoracic air leakThoracic air leak

11OO alveolar or small airway rupturealveolar or small airway ruptureUncommonly tracheal, bronchial or Uncommonly tracheal, bronchial or esophagealesophageal

17

PneumomediastinumPneumomediastinum

Erect PA film more sensitive than AP viewErect PA film more sensitive than AP viewLateral displacement of mediastinal pleuraLateral displacement of mediastinal pleura“Continous diaphragm” sign“Continous diaphragm” sign“Thymus sail” sign“Thymus sail” sign+/+/-- Associated pneumothoraxAssociated pneumothorax// Associated pneumothoraxAssociated pneumothorax

PneumomediastinumPneumomediastinum

Lateral displacement mediastinal pleura

18

PneumomediastinumPneumomediastinum

Air outlining thymus Continuous diaphragm

PneumothoraxPneumothorax

Air in pleural spaceAir in pleural spaceId visceral pleural lineId visceral pleural lineErect PA most Erect PA most sensitive sensitive Lateral decubitus, Lateral decubitus, expiratory or crossexpiratory or crossexpiratory or crossexpiratory or cross--table lateral for small table lateral for small collectionscollections

19

PneumothoraxPneumothorax

Increased Increased thoracic thoracic lucencylucency

PneumothoraxPneumothorax

H idi hH idi hHemidiaphragm Hemidiaphragm sharpnesssharpnessDeep costophrenic Deep costophrenic sulcussulcus

20

Tension pneumothoraxTension pneumothorax

UncommonUncommonMost often with Most often with mechanical ventilationmechanical ventilationLifethreateningLifethreateningLarge sizeLarge sizeMediastinal shiftMediastinal shift

PneumopericardiumPneumopericardium

UncommonUncommonDirect communication Direct communication from pneumothoraxfrom pneumothoraxAir partially or completely Air partially or completely surrounds heartsurrounds heartPericardium sharplyPericardium sharplyPericardium sharply Pericardium sharply outlined by airoutlined by air

21

TrachealTracheal--bronchial Injurybronchial Injury

Cervical tracheaCervical tracheaCervical tracheaCervical tracheaTypically direct blow to anterior neckTypically direct blow to anterior neckLaceration usually longitudinal & posterior at Laceration usually longitudinal & posterior at junction of cartilagenous & membranous tracheajunction of cartilagenous & membranous trachea

Thoracic tracheaThoracic tracheaInjury usually within 2 cm of carinaInjury usually within 2 cm of carinaOften single transverse lacerationOften single transverse laceration

22

TrachealTracheal--bronchial Injurybronchial Injury

NonNon--specific findingsspecific findingsp gp gLarge pneumothorax or Large pneumothorax or pneumomediastinumpneumomediastinumLarge amounts of Large amounts of subcutaneous air in subcutaneous air in neckneck

TrachealTracheal--bronchial injurybronchial injury

Specific findingsSpecific findingsSpecific findingsSpecific findingsAbnl ETT position or configurationAbnl ETT position or configurationTracheal wall defectTracheal wall defectFallen lung signFallen lung sign

23

Esophageal injuryEsophageal injury

Uncommon injuryUncommon injuryU co o ju yU co o ju yMost occur in cervical or upper thoracic Most occur in cervical or upper thoracic Imaging findings nonImaging findings non--specific including specific including left left pneumothorax, pneumomediastinum, pneumothorax, pneumomediastinum, subcutaneous air, left pleural effusionsubcutaneous air, left pleural effusion

Esophageal InjuryEsophageal Injury

24

Esophageal injuryEsophageal injury

Esophagram primary Esophagram primary means of detectionmeans of detectionNonNon--ionic contrast ionic contrast best choicebest choice

Diaphragm injuryDiaphragm injury

L > RL > RMay be occultMay be occultElevated diaphragmElevated diaphragmIndistinct diaphragmIndistinct diaphragmPleural fluidPleural fluidHerniated abdominal Herniated abdominal visceravisceraCT collar signCT collar sign

25

Thoracic traumaThoracic traumaChildren are not small adultsChildren are not small adults

Increased bony pliabilityIncreased bony pliabilityGreater vessel elasticityGreater vessel elasticitySmaller circulating blood volumeSmaller circulating blood volumeSmaller patient sizeSmaller patient sizeSmaller patient sizeSmaller patient size

26

Thoracic traumaThoracic traumaImaging & injuryImaging & injury

11oo assessment w/ radiographyassessment w/ radiographyEnhanced quantification w/ CTEnhanced quantification w/ CTRib fractures injury severity markerRib fractures injury severity markerContusion/laceration injury spectrumContusion/laceration injury spectrum

PEDIATRIC PEDIATRIC CHEST TRAUMACHEST TRAUMA