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Table of Contents   
ORIGINAL ARTICLE
Year : 2018  |  Volume : 23  |  Issue : 1  |  Page : 10-15
 

Challenges in management of pediatric life-threatening neck and chest trauma


1 Department of Pediatric Surgery, All Institute of Medical Sciences, New Delhi, India
2 Department of Trauma Surgery, JPN Trauma Centre, All Institute of Medical Sciences, New Delhi, India
3 Department of Intensive and Critical Care, JPN Trauma Centre, All Institute of Medical Sciences, New Delhi, India

Date of Web Publication27-Dec-2017

Correspondence Address:
Subodh Kumar
Department of Trauma Surgery, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_49_17

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   Abstract 


Introduction: Neck and thoracic trauma in children pose unforeseen challenges requiring variable management strategies. Here, we describe some unusual cases.
Patients and Methods: Pediatric cases of unusual neck and thoracic trauma prospectively managed from April 2012 to March 2014 at a Level 1 trauma center were studied for management strategies, outcome, and follow-up.
Results: Six children with a median age of 5.5 (range 2–10) years were managed. Mechanism of injury was road traffic accident, fall from height and other accidental injury in 2, 3 and 1 patient respectively. The presentation was respiratory distress and quadriplegia, exposed heart, penetrating injury in neck, dysphagia and dyspnea, and swelling over the chest wall in 1, 1, 1, 2 and 1 cases respectively. Injuries included lung laceration, open chest wall, vascular injury of the neck, tracheoesophageal fistula (2), and chest wall posttraumatic pyomyositis. One patient had a flare of miliary tuberculosis. Immediate management included chest wall repair; neck exploration and repair, esophagostomy, gastroesophageal stapling, and feeding jejunostomy (followed by gastric pull-up 8 months later). Chest tube insertion and total parenteral nutrition was required in one each. 2 and 4 patients required tracheostomy and mechanical ventilation. The patient with gastric pull-up developed a stricture of the esophagogastric anastomosis that was revised at 26-month follow-up. At follow-up of 40–61 months, five patients are well. One patient with penetrating neck injury suffered from blindness due to massive hemorrhage from the vascular injury in the neck and brain ischemia with only peripheral vision recovery.
Conclusion: Successful management of neck and chest wall trauma requires timely appropriate decisions with a team effort.


Keywords: Posttraumatic pyomyositis, thoracic injury, traumatic tracheoesophageal fistula


How to cite this article:
Sharma S, Mishra B, Gupta A, Soni KD, Aggarwal R, Kumar S. Challenges in management of pediatric life-threatening neck and chest trauma. J Indian Assoc Pediatr Surg 2018;23:10-5

How to cite this URL:
Sharma S, Mishra B, Gupta A, Soni KD, Aggarwal R, Kumar S. Challenges in management of pediatric life-threatening neck and chest trauma. J Indian Assoc Pediatr Surg [serial online] 2018 [cited 2019 Nov 22];23:10-5. Available from: http://www.jiaps.com/text.asp?2018/23/1/10/221600





   Introduction Top


Thoracic trauma accounts for only 5%–12% of admissions to a trauma center. However, it is the second most common cause of mortality due to trauma, especially in children, after head injury. Children with thoracic trauma may present with diagnostic challenges due to their unique thoracic anatomical and physiological features.[1] The presence of a chest injury increases an injured child's mortality by 20-fold.[2]

The closer proximity of the vital organs in the thorax makes it prone to life-threatening injuries, especially in children where greater forces are applied per unit of body surface area due to the traumatic impact, as compared to adults. Half of the children with thoracic trauma have a multisystem involvement. The initial management of pediatric trauma is based on Advanced Trauma Life Support (ATLS) principles. However, the further management of life-threatening pediatric neck and thoracic trauma requires a multi-team approach and has many lessons to learn for the pediatric surgeon. Although each case requires individualized care, we have compiled our experience in managing some unusual cases involving neck and thorax to form a compendium, including discussion of relevant literature.


   Patients and Methods Top


Pediatric cases, of age less than or equal to 12 years, of unusual neck and thoracic trauma that were prospectively managed from April 2012 till March 2014 at a Level 1 trauma center were studied for the management strategies and outcome.


   Results Top


Six cases of unusual neck and chest wall trauma were managed during this period. All cases were managed as per the ATLS guidelines. Median age was 5.5 years (range 2–10 years). All six patients were boys. The presentation is depicted in [Table 1]. The mechanism of injury was road traffic accident; fall from height during playing, and accidental injury by metal splinter misfired by a goldsmith while sleeping in 2, 3 and 1 patients respectively. The type of injuries, management strategies adopted, and complications encountered are shown in [Table 1]. Associated injuries included spinal injury in one, vertebral injury in one, and depressed skull fracture with fracture femur in one. Three cases had presented with a delayed presentation following trauma; respiratory distress and incomplete quadriplegia 2 weeks after trauma; esophageal perforation and small tracheoesophageal fistula referred with a chest tube 10 days after injury for further management, and posttraumatic pyomyositis following chest wall hematoma 3 days after road traffic accident as he fell from the hands of his mother.
Table 1: Clinical features, management and associated complications of the Cases

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The other patient of tracheoesophageal injury was stabilized and discharged after 20 days. His cervical esophagostomy closed completely in 2-month time, but the patient learnt to spit out his secretions by mouth. At 8-months follow-up, the computed tomography (CT) scan showed a tracheoesophageal defect that was confirmed on bronchoscopy as a defect of 4 cm [Figure 1]a. He developed bradycardia on the operating table when posted for a gastric pull-up due to which the surgery was postponed. On further investigation, no cause could be found, and it was hypothesized that the distended cervical esophageal pouch had produced bradycardia due to compression on the vagus nerve. The distended cervical esophagus measured 5 cm and had a kink on preoperative ultrasonography. A redo gastroesophageal junction dissociation, and retrosternal gastric pull-up with pyloric canal dilatation was done with esophagogastric anastomosis in the neck [Figure 1]b with insert]. The anastomosis healed well in the immediate postoperative period without any leak or stenosis. However, during follow-up, the patient presented with dysphagia due to stricture of the esophagogastric anastomosis that was revised at 26-month follow-up. The redundant cervical esophagus was also excised.
Figure 1: (a) A computerized tomography scan of the chest showing a wide traumatic tracheoesophageal defect. (b) Stomach mobilized and pulled up to replace the esophagus and an esophagogastric anastomosis done in the neck (insert)

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The posttraumatic hospital stay varied from 5 to 38 days [Table 1]. The patient with an open chest wall was repaired immediately, the subcutaneous tissue and skin were closed as a delayed primary closure [Figure 2]. He could be discharged in 5 days. Four patients required therapeutic artificial mechanical ventilation while one was electively ventilated postoperatively. Two patients on prolonged artificial ventilation and inotropes required tracheostomy for better tracheal toileting. Both the patients were successfully weaned off the ventilator, kept on T-piece for few days and decannulated before discharge. Early complications were seen in five patients [Table 1]. Operative interventions (1–3) were required in five patients. The patient with vascular injury of the neck developed hydrocephalus, for which a ventriculoperitoneal shunt was put. He later had posterior cerebral venous ischemic infarct as a later complication due to massive hemorrhage from the vascular injury in the neck and brain ischemia, leading to blindness. He had a peripheral vision recovery at 3-month follow-up. The other five patients are well. Hence, at a follow-up of 40–61 months, all 6 patients are alive.
Figure 2: (a) Open chest wall showing a beating heart. (b) Computed tomography scan done during the postoperative period. (c) Subcutaneous tissue and skin were closed as a delayed primary closure

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   Discussion Top


Thoracic injuries in children are not so common and only about 10%–15% require operative intervention.[3] Fortunately, the majority of thoracic trauma in children requiring treatment is due to blunt trauma.[4] A high index of suspicion is needed to suspect a dangerous mechanism of injury. The compliant pediatric thorax and pliable cartilage and bony thoracic cage enable the chest to absorb a large amount of kinetic energy from the impact, which is subsequently transferred to the intrathoracic structures. Thus, often the child may have major intrathoracic injury with minimal or no injury to the thoracic bony cage comprising of the ribs, sternum, and scapula. Thus, pulmonary contusion has been reported as the most common thoracic injury that may comprise up to 50% of the cases.[3],[5]

Penetrating trauma constituting 15% of chest injuries in children are seen most often in war-hit countries, caused by gunshots, knife wounds, and injury from other sharp objects. In cases of penetrating pediatric neck and chest trauma, there is great urgency as a relative small blood volume loss can lead to hypovolemia and shock, due to the low volume of blood in children. The case of penetration neck injury that presented to us had already bled a lot at the site of trauma and at another peripheral hospital before he was referred to us. The metallic splinter had traversed the posterior wall of the internal jugular vein and during surgery had travelled to the brachiocephalic vein due to the negative venous pressure. It was very difficult to retrieve the metallic piece from the pool of blood on the table. The child had required massive blood transfusion, and the subsequent complications were hemorrhagic shock, and coagulopathy. While the cause of mortality in penetrating injuries is the penetrating injury itself, the cause of mortality in half of the blunt trauma cases is neurological injury.[3] The associated head injury is also an important cause of mortality.

Resuscitation of the child with thoracic trauma begins with a survey for immediate life-threatening injury.

Major thoracic injuries are known as the deadly dozen.[6] The immediate life-threatening thoracic injuries or lethal six including airway obstruction, open pneumothorax, tension pneumothorax, massive hemothorax, flail chest, and cardiac tamponade should be identified in the primary survey. The potential life-threatening thoracic injuries or hidden six including pulmonary contusion, widened mediastinum/aortic transection, ruptured tracheobronchial tree, ruptured diaphragm, esophageal perforation, and myocardial contusion should not be missed during the secondary survey. Out of the six cases described here, two had life-threatening emergencies, whereas three had potential life-threatening injuries. The case of pyomyositis had also become a potential life-threatening injury due to the setting in of sepsis.

A thorough and focused evaluation for thoracic injuries is required to discover the extent and severity of these injuries.[7] Failure to promptly diagnose immediate life-threatening thoracic injuries and treat these injuries results in exponentially increased morbidity and mortality that may approach 50%.[2],[7] Holmes et al. reported the predictors of thoracic injury in children sustaining blunt torso trauma as low systolic blood pressure, elevated respiratory rate, abnormal results on thoracic examination, abnormal chest auscultation findings, femur fracture, and Glasgow Coma Scale score of <15.[8]

A chest X-ray is sufficient in most cases. A CT scan is advised only after stabilization to decide the further course of management. Holscher et al. concluded after comparing chest CT scan imaging and chest radiographs that CT scan did not add to the management of the trauma and increased the risk from radiation.[9] In the case with lung laceration with spinal injury, a diagnosis of miliary tuberculosis could be made due to the presence of mediastinal lymphadenopathy and pericardial effusion on CT scan and cervical spine contusion on magnetic resonance imaging. He was regularly monitored with echocardiography to assess the heart function. He did not respond to prolonged higher antibiotics but responded on initiation of antitubercular treatment.

Less than 15% of cases of thoracic trauma in children require thoracotomy. None of the cases described here needed a formal thoracotomy, though multiple surgeries were required including tracheostomy and neck and abdomen exploration for gastric pull-up.

Sequelae of pulmonary contusion in children include pneumonitis and posttraumatic pseudocysts, as the more elastic and pliable chest wall of children permits the transmission of kinetic energy more efficiently to the underlying lung parenchyma.[10] The concussive forces of a high-velocity impact with low displacement of the chest wall result in a peripheral pseudocyst, whereas the compressive forces of a low-velocity impact with high displacement of the chest wall resulting in a central pseudocyst.[11] These typically resolve with antibiotics and time.

Children presenting after blunt chest trauma may have complete disruption of the airway with little external sign of injury. The suspicion should be high in the presence of pneumothorax and pneumomediastinum that are refractory to adequate pleural drainage.[12] Bronchoscopy is helpful to identify the location of injury. Guided flexible bronchoscopy with intubation distal to the injury was used to intubate the child with tracheoesophageal fistula described here to give general anesthesia. Advance preparation for a cardiopulmonary bypass along with thoracotomy should be done in case primary repair is contemplated.

In many instances with trivial tracheobronchial trauma, the diagnosis may be missed. In a 10-year review of delayed diagnoses of traumatic tracheobronchial injuries, the median time from initial presentation to diagnosis was reported as 6 months.[13] Dyspnea (56%) and pneumonia (39%) were the most common complaints.[13] Bronchial sleeve resections or end-to-end anastomosis can be performed safely in most situations.[13] There was no difference in complications was observed between parenchymal sparing procedures and resections.[13]

Early diagnosis of esophageal injury significantly reduces the complications and mortality. Perforations of the cervical esophagus can present with neck pain, cervical dysphagia, dysphonia, or regurgitation of blood. Intrathoracic perforations can rapidly contaminate the mediastinum, leading to chest pain, tachycardia, tachypnea, fever, and leukocytosis. Children are often not able to communicate the symptoms, and sick look of the child with painful respiration should raise the suspicion for further evaluation. A chest X-ray may reveal mediastinal widening with or without an air-fluid level, subcutaneous emphysema, and a pleural fluid collection. A lateral skiagram of the neck may reveal air in the prevertebral fascial planes in cervical esophageal perforation. On suspicion of an esophageal perforation, a water-soluble contrast study should be performed. A well-contained leak can be managed with careful observation, successful negotiation of a nasogastric tube if feasible under guidance, keeping the patient nothing by mouth, broad-spectrum antibiotics, and total parenteral nutrition. A chest tube may be inserted if there is thoracic collection. This may be progressed to drip in feeds after 2 weeks. The contrast study may be repeated after 3 weeks to check for the healing.

If the leak is not contained, the site of perforation dictates further management. If the patient is stable and the defect is less than 3 cm, the esophagus may be explored. The upper- and mid-esophagus are best approached through the right side of the chest, whereas the lower third of the esophagus and the esophagogastric junction are best approached through the left side of the chest. Some pleural or intercostal muscle covering should accompany debridement and primary repair. Wide drainage of both the mediastinum and pleural space is mandatory. Video-assisted thoracoscopic drainage for esophageal perforation with mediastinitis in children has been shown to be feasible and effective.[14]

In unstable patients, in the presence of inflammation and infection, extensive injury, large tracheoesophageal communication more than 3 cm and in cases with life-threatening tracheoesophageal injury as in one case described here, a diversion procedure in the form of cervical esophagostomy in emergency is lifesaving. This may be followed by eventual esophageal replacement.

The case described here has a residual piece of esophagus attached to the posterior wall of the trachea and is in regular follow-up to see for any complication. The gastroesophageal junction had opened up as demonstrated during the surgery for gastric pull-up. The gastroesophageal junction has now been disconnected completely as high as possible through the abdomen.

He et al. described successful surgical management of 3 cases including a 6-year-old child with huge posttraumatic tracheoesophageal fistula (>5 cm in length) with esophagus segment in situ as replacement of the posterior membranous wall of the trachea.[15]

One of the cases had a posttraumatic pyomyositis that presented as a soft-tissue swelling over the chest wall. Pyomyositis is a purulent infection of skeletal muscle that arises from hematogenous spread, usually with abscess formation.[16] Predisposing factors for pyomyositis include immunodeficiency, trauma, injection drug use, concurrent infection, and malnutrition.

Mechanical ventilation in children after chest trauma requires a balance between sufficient ventilation and the avoidance of barotrauma to the inflamed lung parenchyma.[17] An elective tracheostomy was done in two patients to support the lung toilet while on ventilator. Tracheostomy in a child is a concern and requires weighing the risks versus the merits.[18],[19] With sophisticated, patient-friendly tracheostomy tubes, the use may be extended to selected children in whom prolonged ventilatory support more than 2 weeks is anticipated.

It has been reported that regardless of the mechanism of thoracic trauma, 15%–25% of children with thoracic injury do not survive, depending on the severity of the drainage of patients to the level of hospital.[20],[21] The mortality is around 5% for isolated thoracic trauma and increases with concomitant injuries, up to 20%–25% with abdominal, 30%–35% with head injuries, and 40% with combined head, thorax, and abdominal injury.[20],[21] The mortality in thoracic injuries depends on the organ involved. Peclet et al. reported that injuries to the heart or great vessels had the highest mortality rate (75%), followed by hemothorax (53%), lung laceration (43%), and rib fracture (42%).[20]


   Conclusion Top


About 75% of pediatric chest injuries worldwide are caused by motor vehicle accidents, with the remainder attributable to motorcycle-related trauma, falls, and bicycle accidents. These are thus preventable injuries. Awareness on preventive aspects would help to prevent a potential cause of morbidity and mortality.

There can be a varied presentation of life-threatening neck and chest wall trauma in children. Successful management requires repeated evaluation and timely appropriate decisions. The surgical options should be considered appropriately without haste. The life-threatening cases described here were adequately managed and survived. Even cases with a delayed diagnosis and complications can be managed successfully with a goal-directed multidisciplinary team effort. All pediatric surgeons should adopt the ATLS principles religiously in the initial assessment and management of traumatic cases to prevent immediate mortality and limit morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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He J, Chen M, Shao W, Li S, Yin W, Gu Y, et al. Surgical management of 3 cases with huge tracheoesophageal fistula with esophagus segment in situ as replacement of the posterior membranous wall of the trachea. J Thorac Dis 2009;1:39-45.  Back to cited text no. 15
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