Thoracic Trauma

Question 1

Presentation of tracheobronchial injuries?

Answer 1

Most common symptom is extensive SC emphysema. Also have dyspnea, sternal tenderness and hemoptysis

Large volume air leak from chest tube.

Question 2

What is the pathophysiology of traumatic asphyxia?

Answer 2

Direct compression of chest during deep inspiration and closed glottis causes massive increase in intrathoracic pressure transmitted through vena cava leading venous disruption along the distribution of the SVC.

Question 3

Managment of trachobronchial injury?

Answer 3

-Attempt to isolate the injured lung to provide ventilation/minimize air leak with double lumen tube or main stem intubation.

Large air ways should be repaired primarily ASAP with absorbable suture and buttressed with healthy tissue.
Small air ways (lobar) can be resected with lobectomy.

Small tears may heal without surgery but can stricture.

Question 4

Mortality with tracheobronchial injury?

Answer 4

~1/3 with 50% of mortalities in the first hour.

Question 5

What percentage of children with traumatic pneumo present with tension?

Answer 5

25% - increased mobility of mediastinum predisposes to this.

DDx: tamponade, ET tube malposition/obstruciton, severe gastric distension.

Question 6

Does occult pneumothorax require a chest tube?

Answer 6

No and this is safe with PPV.

Question 7

What are the indications for thoractomy due to Hemothorax?

Answer 7

15ml/Kg on placement of chest tube or ongoing drainage of 2-3 ml/kg/hr over 6 hours.

Question 8

what percent of children with pulmonary contusion develop pneumonia?

Answer 8

20%

Question 9

Management of traumatic pneumatocele?

Answer 9

Generally observation as this is common in children and self resolves.

Question 10

Work up penetrating trauma near the mediastinum?

Answer 10

CTA
Bronch
EGD

Question 11

Percent of blood volume held by pediatric chest?

Answer 11

40%

Question 12

Criteria for non-operative management of trachobronchial injury?

Answer 12

Less than 1/3 circumference or short longitudinal tear.

Question 13

Indications for surgery in penetrating chest trauma?

Answer 13

Tamponade
Massive hemorrhage (15/kg or 2-3/kg/hr)
Significant tracheobronchial injury

Question 14

Indications for ED thoracotomy?

Answer 14

Penetrating trauma with no signs of life with CPR < 15 min.

Penetrating trauma with refractory shock or requiring CPR with signs of life.

Question 15

Criteria and treatment for non-op mgmt of esophageal injury?

Answer 15

Small contained leak on esophogram.

NPO, IV
Abx
Consider chest tube.

Question 16

Approach and technique for esophageal repair?

Answer 16

Repair all uncontained leaks

Lower esophagus is best accessed through the left chest

Upper through the right.

Two layer repair with buttress of healthy tissue.

Question 17

Management of delayed diagnosis of esophageal perforation?

Answer 17

Consider T-tube drain through perforation site.
Wide drainage
If severe perform cervical esophagostomy and staple off distal esophagus.
Reconstruct in several months.

Question 18

Mortality associated with rib fractures in children?

Answer 18

42%

Number of rib fractures predicts increasing mortality.

Question 19

Two most common causes of rib fractures?

Answer 19

MVC 70%

NAT 20%

Question 20

What is commotio cordis?

Answer 20

Cardiac arrest associated with blunt trauma to the chest. May be minor blow but can induce V. Fib. - good response to defibrillation.

Question 21

What children require cardiac monitor for blunt cardiac injury?

Answer 21

ECG changes and elevated troponin.