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PEDIATRICPEDIATRICPEDIATRIC PEDIATRIC CHEST TRAUMACHEST TRAUMA
Children are not small adultsChildren are not small adultsRole of imagingRole of imagingSpectrum of injurySpectrum of injury
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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
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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
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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
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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
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Initial supine exam Repeat erect exam
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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
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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
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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
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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
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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
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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
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Initial exam F/U 3 days later
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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
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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
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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
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PneumothoraxPneumothorax
Increased Increased thoracic thoracic lucencylucency
PneumothoraxPneumothorax
H idi hH idi hHemidiaphragm Hemidiaphragm sharpnesssharpnessDeep costophrenic Deep costophrenic sulcussulcus
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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
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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
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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
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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
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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
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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
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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