|Year : 2019 | Volume
| Issue : 4 | Page : 264-270
Pediatric thoracoabdominal trauma: Experience from a tertiary care center
Vijay Kumar Kundal, Pinaki Ranjan Debnath, Atul Kumar Meena, Shalu Shah, Prafull Kumar, Shyam Sunder Sahu, Amita Sen
Department of Pediatric Surgery, PGIMER and Dr. RML Hospital, New Delhi, India
|Date of Web Publication||29-Aug-2019|
Dr. Pinaki Ranjan Debnath
Department of Pediatric Surgery, PGIMER and Dr. RML Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of this study is to assess the pattern and mode of thoracoabdominal trauma and anatomical organ involvement, type of management employed, and overall outcomes in the pediatric population.
Materials and Methods: A retrospective study conducted at a tertiary hospital over a period of 38 months with a total of 198 pediatric patients <12 years of age with a history of abdominal and chest trauma between July 2014 and September 2017 were reviewed. Case files of all pediatric patients were evaluated. Information regarding age, sex, mechanism of injury, site of injury, mode of injury, nature of the injury, definitive treatment required, whether conservative or surgical and outcome of patients was evaluated. site of injury, mode of injury, nature of the injury, definitive treatment required, whether conservative or surgical and outcome of patients was evaluated.
Results: A total of 198 patients of thoracoabdominal trauma patients were studied. The majority of pediatric thoracoabdominal trauma cases were observed in males (n = 128, 64.64%) and females comprise only 35.35% (n = 70). Fall was the most common mode of trauma (58.08%) followed by road traffic accidents (30.30%), thermal injuries (9.09%) assaults in order of decreasing trends. The abdomen was the most common anatomical site of the injury (45.95%) followed by combined thoracoabdominal trauma (32.32%) followed by thoracic trauma (21.71%). Among the thoracic trauma, the most common comprised the lung contusions (37.20%) followed by the lung laceration comprising (25.58%) and rib fractures comprised only 20.93%. Among the abdominal trauma, the most common organ of injury was the liver (36.26%) followed by splenic trauma in 19.78% of patients. Approximately, 85% of patients were managed conservatively, and only 15% required major surgical intervention in the form of laparotomy and repair of bowel perforation, thoracotomy and ligation of bleeding intercostal vessels, partial and total splenectomy, repair of the liver laceration, and nephrectomy for the patient of Grade 5 renal injury with expanding retroperitoneal hematoma. Three patients died, one of which was Grade 5 renal injury with expanding retroperitoneal hematoma, two others were cases of combined thoracoabdominal trauma with massive hemothorax and both liver and splenic injury.
Conclusion: The study defines the pattern of thoracoabdominal trauma, mode of trauma, and the prevalence of different organs involved in both the chest and abdominal cavity. We concluded that main indications for performing an operative intervention included severe hemodynamic instability, pneumoperitoneum, massive pneumohemothorax with significant shift and definitive confirmation of oral contrast leak on computed tomography films. A detailed trauma registry in our set up seems important for managing pediatric thoracoabdominal trauma.
Keywords: Liver contusions, nonoperative management, splenic laceration, thoracoabdominal trauma, thoracotomy
|How to cite this article:|
Kundal VK, Debnath PR, Meena AK, Shah S, Kumar P, Sahu SS, Sen A. Pediatric thoracoabdominal trauma: Experience from a tertiary care center. J Indian Assoc Pediatr Surg 2019;24:264-70
|How to cite this URL:|
Kundal VK, Debnath PR, Meena AK, Shah S, Kumar P, Sahu SS, Sen A. Pediatric thoracoabdominal trauma: Experience from a tertiary care center. J Indian Assoc Pediatr Surg [serial online] 2019 [cited 2019 Sep 15];24:264-70. Available from: http://www.jiaps.com/text.asp?2019/24/4/264/265692
| Introduction|| |
Pediatric trauma is the major cause of mortality and disability worldwide and accounts for a significant burden on countries with limited resources. Pediatric trauma is also the cause of more than half the deaths among children aged 1–14 years and are the 2nd leading cause of hospital emergency consultations after infections. Worldwide, about five million children die from trauma each year accounting for nearly one in every 10 deaths. The National Crime Record Bureau (NCRB), an Indian government agency, data reveal the nearly 15%–20% of trauma deaths occur among children. As per the NCRB report of 2006, there were about 22,000 deaths in the age group of <14 years due to the injuries.
Pediatric abdominal trauma is the 3rd leading cause of death. The incidence of pediatric blunt abdominal injury is approximately 9/1 lakh children. Blunt abdominal trauma is more common than that of penetrating abdominal trauma, and the mechanisms of injury vary among the different age groups.
Pediatric thoracic injuries occur in 4%–6% of hospital trauma patients. In isolation, thoracic trauma carries a 5% mortality and 25% mortality when combined with abdominal injury., Blunt and penetrating chest trauma in children results from many causes, but the major cause is motor vehicle accidents. The trauma causes a variety of injuries to the rib cage, lung parenchyma, and other mediastinal structures.
Knowledge regarding the pattern of pediatric abdominal and thoracic trauma is essential for the planning, implementation, and management of trauma at the initial level to decrease the mortality and morbidity resulting from this global pandemic., This study is an attempt to describes the pattern of pediatric abdominal and thoracic trauma, type of organ injury, and type of intervention employed whether conservative or surgical.
| Materials and Methods|| |
This is a retrospective observational study conducted at a tertiary care hospital over a period of 38 months. A total of 198 pediatric patients <12 years of age with a history of abdominal and chest trauma between July 2014 and September 2017 were included in the study. For the purposes of our study, the thoracic injury was defined as any injury between the clavicles superiorly and the 12th rib inferiorly, which resulted in a clinically significant or suspected intrathoracic injury. Exclusion criteria included pediatric head, spine and facial injuries, pediatric upper and lower limb injuries, poisoning cases, and drowning patients and patients with psychiatric illnesses. Case files of all the pediatric patients <12 years of age were evaluated. Information regarding age, sex, mechanism of injury, site of injury, mode of injury, nature of the injury, definitive treatment required, whether conservative or surgical and outcome of patients was evaluated. All the patients of thoracoabdominal trauma were initially evaluated with X-ray skeletal survey and focussed assessment with sonography for trauma (FAST) and all FAST positive and clinical stable cases were evaluated with ultrasound (USG) in details. Positive USG findings mandated evaluation in details by contrast enhanced computed tomography (CECT) chest and abdomen and pelvis. All patients were managed as per standard Advance Trauma Life Support (ATLS) guidelines.
| Results|| |
During the total study period of 3 years, a total of 198 patients of pediatric thoracoabdominal trauma reported to us in the hospital. The mean age of these patients was 6.2 years, with ages ranging from 3 months to 12 years. There was a strong sex bias, as 64.64%, (n = 128) of patients were boys and females comprises only 35.35% (n = 70).
Fall was the most common mode of trauma (n = 115, 58.08%) followed by road traffic accidents, which comprises only 30.30% (n = 60), followed by thermal injuries (n = 18, 9.09%) in the form of scalds, superficial and deep burns and electrical injuries [Figure 1]. All thermal burns were referred to burn unit for further management. Assaults comprise the least common mode of trauma (n = 5, 2.52%). Out of total 198 patients of thoracoabdominal trauma, abdomen was the most common anatomical site of injury (n = 91, 45.95%) followed by combined thoracoabdominal trauma in 64 patients (32.32%). Thoracic trauma was least commonly involved site in trauma (n = 43, 21.71%) [Figure 2].
|Figure 1: Pie chart describing mode of trauma among patients of thoracoabdominal trauma|
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Out of the total 43 patients of isolated thoracic trauma, most common comprised the lung contusions with hemopneumothorax (n = 16, 37.20%) followed by lung laceration with hemopneumothorax comprising 25.58% (n = 11) and rib fractures with hemopneumothorax comprised nine cases (20.93%). Clavicle fractures comprises 9.30% (n = 4). Sternal injuries and pericardial hematoma were least common comprising only 4.65% (n = 2) and 2.32% (n = 1), respectively [Figure 3]. Out of total 91 patients of isolated abdominal trauma, most common organ of injury was liver (n = 33, 36.26%) followed by splenic trauma in 18 patients (19.78%) [Figure 4], [Figure 5], [Figure 6], [Figure 7]. Hollow viscus injury and kidney trauma comprise only 15 cases (16.48%) and 12 cases (13.18%). Pancreatic injuries and urinary bladder injuries comprised the least common injuries, i.e., nine cases (9.89%) and four cases (4.39%), respectively [Figure 8]. All the cases of thoracoabdominal injuries were initially evaluated by radiological imaging in the form of X-ray skeletal survey, FAST and CECT in FAST positive cases.
|Figure 4: Coronal section of computed tomography showing grade III left renal injury|
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|Figure 5: Coronal section of computed tomography showing grade III right Lobe of Liver injury|
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|Figure 6: Coronal section of computed tomography showing grade III splenic injury|
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|Figure 7: Computed tomography films with combined liver and splenic injury|
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|Figure 8: Bar chart showing different organ involvement in isolated abdominal trauma|
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Combined thoracoabdominal trauma comprised a significant proportion of cases (n = 64, 32.32%), i.e., approximately one-third cases of total thoracoabdominal trauma. Most of the cases included combined chest injuries with liver trauma (n = 21, 32.81%) followed by combined chest injuries with liver n splenic lacerations (n = 17, 26.56%), followed by chest injury with splenic trauma (n = 15, 23.43%). Chest injury with diaphragmatic injury with liver injury comprised the least common injury (n = 2, 3.12%) [Figure 9].
|Figure 9: Bar chart showing distribution of combined thoraco-abdominal trauma among different organs|
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Most of pediatric thoraco-abdominal trauma are managed conservatively (56.56%, n = 112) followed by minor intervention (requiring local anesthesia only) in 28.28% (n = 56). Major interventions were required in only 15.15% of cases (n = 30) [Figure 10].
All patients of bowel perforation required surgical intervention (100%, n = 21/21). Out of the total of 21 cases of bowel perforation, nine had jejunal, five had cecal, three had splenic flexure of the colon, 3 had illeal, and 1 had duodenal perforation each. Treatment consisted of simple closure of perforation in 15 patients, resection and anastomosis in three patients and stoma in three patients in view of gross contamination and delayed presentation. Out of the total of 50 patients of splenic trauma, only three patients (6%) required surgical intervention (two required partial splenectomy and one patient required total splenectomy). Only 5.63% (n = 4/71) of patients of liver injury required surgical exploration in view of persistent hemodynamic instability despite adequate resuscitation with fluids and blood and strong clinical suspicion of hollow viscus perforation. Intraoperatively, repair of liver laceration was done. One out of a total of nine patients of pancreatic injury required surgical intervention for a delayed pseudopancreatic cyst (11.11%). One patient (8.3%) of Grade 5 renal injury required nephrectomy out of total 12 renal injury cases. Thoracotomy was required in 2.80% (n = 3/107) because of increased chest tube drainage of blood and hemodynamic instability despite adequate resuscitation with crystalloids and blood products. Ligation of bleeding intercostals vessels and repair of lung laceration was done in two cases and one patient required delayed decortication. Intercostal chest tube (ICD) insertion comprised the maximum percentage of cases, i.e., 52.33% (n = 56/107). Repair of urinary bladder perforation was required in one patient out of four patients of bladder injuries [Figure 11]. A total of three patients died during the period, one was a case of Grade 5 renal injury with expanding retroperitoneal hematoma, in which nephrectomy was done. Two other comprised cases of combined thoracoabdominal injury with multi-organ involvement. Cause of death in these two cases was hemorrhagic shock.
|Figure 11: Type of surgical intervention required in thoracoabdominal injuries|
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| Discussion|| |
Trauma injuries are one of the main causes of morbidity and mortality among the pediatric population both in developed and developing countries. Trauma injuries are considered 2nd leading cause of emergency admissions after infections. Trauma accounts for about 12% of the disease burden worldwide and places a significantly increased burden on countries with limited resources. Sharma et al. concluded that by knowing the epidemiological parameters of pediatric trauma, majority of these injuries are preventable. The incidence of pediatric thoracoabdominal injuries has increased significantly over the past few decades. About two-third of pediatric thoracic injuries are caused by motor vehicle accidents followed by fall from height. Blunt trauma abdomen accounts for the large majority of abdominal injuries in the pediatric population, and it outnumbers penetrating abdominal trauma and its mechanism is different in varying age groups. Motor vehicle-related injuries, whether as passenger or driver, bicyclist, or pedestrian are considered the most common cause of pediatric blunt abdominal trauma. Falls, sports-related injuries and recreation-related injuries are the other mechanisms of abdominal injuries in children. There are specific injury mechanisms that should lead the treating doctor to suspect the presence of intra-abdominal injury. Children have unique anatomy and more labile physiologic reserve, less protective adipose tissue, connective tissue and muscle mass. Bones of children are not completely calcified, which allows them to be more pliable. In children, the intra-abdominal organs are more closely situated to each other, and there are more chances of injury to multiple organs. The incidence of blunt pediatric abdominal trauma is approximately 9/1 lakh children. Similarly, chest injuries are considered a marker of significant trauma and thorax because of its size, and the anatomical location is considered the major site of trauma.
Management of both thoracoabdominal injuries has undergone a major shift from surgical intervention to nonoperative management due to the ability to accurately evaluate the grade of injury of thoracic and abdominal organs with USG and CT. Most of the blunt injuries are managed nonoperatively, but the decision not to operate must be made by trauma surgeon based on hemodynamic status and CT findings and rational decision and as per standard ATLS guidelines.
The study concludes that male children are more common victims of trauma than females. Fall is considered the most common mode of trauma in the pediatric population till 12 years of age (58.08%, n = 115). Similarly, a study by Hyder et al. documented that an average of 36% of all injuries are due to falls in children <5 years of age with Africa having an incidence rate of 786/1.0 lakh. Another study by Poudel-Tandukar et al. from Nepal also concluded that falls are the most common mode of injury in 65% of trauma-related children. However, a previous study by Kundal et al. reported that road traffic accidents are the most common mode of injury. It is possibly due to the inclusion of higher age of 15 years in pediatric trauma in his study. The present study concludes that road traffic accidents are the 2nd most common mode of injury followed by thermal injuries followed by assaults. Our results are consistent with most of the studies published in the literature. Abdomen comprised the most common anatomic site of injury followed by combined thoracoabdominal injuries, followed by thoracic injuries out of the total 198 patients of thoracoabdominal injuries [Figure 4], [Figure 5], [Figure 6], [Figure 7].
Among the total of 107 cases of thoracic trauma (isolated thoracic trauma plus thoracoabdominal trauma cases), 48 cases were managed conservatively with intravenous fluids, nonsteriodal anti-inflammatory drugs and rest. Fifty-six patients were managed by ICD drainage of isolated thoracic trauma cases and three patients were managed by thoracotomy in view of increased chest tube drainage of blood and hemodynamic instability despite adequate resuscitation with crystalloids and blood products. Intraoperatively, ligation of bleeding intercostals vessels with repair of lung laceration was done in two patients and one patient required decortication. A review by Reynold also concludes that most of the pediatric thoracic trauma cases are managed by chest tube insertion and very rarely require operative intervention in the form of thoracotomy. A study by Ismail and al-Refaie from Egypt reported Lung contusion, lung laceration, rib fractures in 23.7%, 6.9%, and 23.9% of cases, respectively. Possible reasons for the decreased incidence of rib fractures in comparison to lung contusion and lacerations are due to extreme pliability, flexibility, and noncalcification of pediatric ribs.
Among the total patients of abdominal trauma, liver injuries are the most common in our study (36.26%) followed by splenic trauma (19.78%), renal trauma (13.18%) followed by hollow viscus injuries (16.48%) pancreatic injuries (9.89%) and urinary bladder injuries (4.39%). Literature reports spleen to be the most common organ of injury followed by liver injuries. In another study, Liver sustained injuries in 7.8% of all abdominal injury cases. Studies by Dodgion et al. and Notrica concludes that conservative management is considered the standard protocol in the management blunt abdominal solid organ injuries, with >96% of isolated injuries managed without surgery.,
All patients (n = 21) of bowel perforation required surgical intervention in our study. Most common site of intestinal perforation was jejunum (n = 9) followed by caecum (n = 5) followed by splenic flexure of colon (n = 3) followed by Ileum (n = 3) and duodenum (n = 1). Treatment consisted of simple closure of a perforation in 15 patients, resection and anastomosis in three patients and stoma in three patients in view of gross contamination and delayed presentation. Bowel perforation was confirmed either by pneumoperitoneum, clinical examination or by contrast leakage from CT. Bowel injuries comprise a significant number of patients mostly due to RTA and handlebar injuries., Out of the total of 50 patients of splenic trauma, only three patients required surgical intervention. Operative intervention should only be considered for the pediatric patient with an injured spleen who is clinically unstable despite adequate resuscitation. Only 5.63% of patients of liver injury required surgical exploration in the form of repair of liver laceration. Our results regarding conservative management of most of the solid organ injury are consistent with published data in the literature. One out of a total of nine patients of pancreatic injury required surgery for a delayed pseudopancreatic cyst (11.11%). Lower grade pancreatic injuries are managed with a conservative approach and higher grade injuries require operative management in the form of distal pancreatectomy, Roux-en-Y drainage or endoscopic management. One patient (8.3%) of Grade 5 renal injury required nephrectomy of total 12 renal injury cases. Renal injuries are less common than liver or splenic trauma in view of the retroperitoneal location of the organ. Failure of conservative management occurs in high grade renal injuries in <3% of cases as per literature. Successful management of these injuries requires repeated evaluation and timely appropriate decisions.Repair of urinary bladder perforation was required in one patient out of four patient of bladder injuries.
There are few limitations in our study that need to be described. First, the present study addresses the pediatric chest and abdominal trauma patients that received attention at the emergency department of our tertiary care institution. It does not include polytrauma cases involving the head-and-neck injuries. There is also the possibility of selection bias in registering the patients. Patients of drowning and poisoning are not included in the study, as these patients reported to the pediatric physician in charge of the emergency department. Their inclusion also might have influenced the study.
| Conclusion|| |
Our study defines the pattern of thoracoabdominal trauma among males and females, mode of trauma among the studied population, the prevalence of different organs involved in both chest and abdominal cavity combined or separately. Majority of these trauma cases can be managed by the nonoperative approach and clinical monitoring. In our experience, main indications for performing an operative intervention included severe hemodynamic instability, pneumoperitoneum, pneumohemothorax with significant shift, and definitive confirmation of contrast leak through CT.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]