Editing Paediatric trauma (section)

== Thoracic trauma ==
Overall approach

* Keep in mind that significant internal injury is possible without rib fractures in children
* Children are predisposed to hypoxia due to lower FRC
* Children are at risk of obstructive shock from tension PTX due to a highly mobile mediastinum
* Vast majority of paeds thoracic trauma is blunt


Rib fractures

* Infrequent <8yo due to chest wall compliance
* Suspicion NAI esp <3yo
* Seems like they are essentially managed as in adults

Flail chest

* Extremely rare
* Manage as in adults

Open PTX

* Usually a/w blast injury/impalement
* High risk tension due to one way valve
* Needs chest tube and completely occlusive dressing
* If chest decompression is unavailable, a 3-sided dressing is used

Lung contusion

* Most common thoracic injury in children
* Usually self-resolves within a week without requiring resp support
* Seen on CXR
* Can be complicated by PTX or HTX or infection
* Supportive management, observing in case respiratory failure occurs and they require ventilation

Pneumothorax/haemothorax

* Note that each hemithorax can hold up to 40% of a child's blood volume! This can kill!
* Asymptomatic PTX (not seen on CXR) does not necessarily require drainage, but must be carefully observed
* Some guidelines say ALL paediatric HTX should be drained - discuss with paeds trauma team

Diaphragmatic rupture

Tracheobronchial injury

* Usually due to high acceleration/deceleration
* Usually membranous trachea, 2-3cm from carina
* Look for upper airway signs, which may also have features of PTX
* Can be diagnosed after chest tube insertion when there is persistent PTX/pneumomediastinum/constantly bubbling chest drain, and would need bronchoscopy
* Usually requires surgery

Oesophageal injury

* Diagnose contrast study/endoscopy/CT



Indications for thoracotomy

* Ongoing bleeding from ICC equivalent to 2-3ml/kg/hr over 3 hours
* Oesophageal disruption
* Tracheobronchial disruption
* Diaphragmatic injury
* Penetrating cardiac injury

Median sternotomy is the preferred approach if there is time

Resuscitative thoracotomy would be done through left anterolateral thoracotomy in 5th intercostal space.