PEDIA

TRIC

PENETR

ATIN

G

TRA

UM

A

Laura Boomer

11/18/15

PENETRATIN

G TH

ORA

CIC TRAU

MA

�Traum

a is the major cause of m

orbidity and mortality in children

�Penetrating traum

a (in general) accounts for only approximately 2%

of all pediatric traum

a

�Thoracic traum

a accounts for only 4-12% of pediatric traum

a admissions

�M

ay cause 6-10% of fatalities

�Penetrating thoracic traum

a accounts for only 10-20% of all pediatric thoracic

trauma

�Recently, w

e have seen a number of penetrating thoracic traum

a

RC

�14 yo M

handling homem

ade explosives when one w

ent off and he sustained a blow

to his chest (8/2) – trauma stat

�Patient’s m

om (w

ho is an ICU nurse) placed pressure on his axilla w

here bleeding w

as coming from

�PE: w

ound at the posterior axillary line just distal to the hairline �

Clothing blood soaked, but no active bleeding �

+ palpable distal pulses

�CTA

done: shows m

oderate axillary artery extravasation

RC

RC

�O

R: angiogram perform

ed, with exploration of right axillary fossa

�Significant hem

atoma; brachial plexus carefully retracted out of the w

ay �

Injury to axillary artery and vein – both were able to be prim

arily repaired with 6-0

prolene �

Closed over a blake drain

�A

dmitted to PICU

overnight (early am on 8/3)

�Placed on aspirin 81 m

g post-op

�Transferred to floor on 8/4

�D

rain removed and patient discharged on 8/5, aspirin x 30 days

�Seen in vascular clinic on 8/17 – som

e weakness in ulnar distribution, but w

orking w

ith PT/OT

PH

�14 yo M

, GSW

to chest, initially seen at Baptist-DeSoto (8/11)

�Believed to be self-inflicted

�Transferred as traum

a stat

�D

ecreased strength left hand grip and wrist flexion

�1 x 2 cm

wound to anterior left upper chest (3 sutures in place w

ere removed)

�2.5 x 2.5 cm

wound to upper left back

�CTA

: comm

inuted left scapula fracture �

Pulmonary contusion

�Possible 2m

m traum

atic pseudoaneurysm arising from

proximal axillary artery

PH

PH

PH

�O

R: left shoulder explored through an infraclavicular incision �

No arterial injury

�Paired vein – 1 w

as intact, 1 transected – this was ligated

�A

rteriogram perform

ed through the axillary artery – demonstrated patent subclavian

and axillary artery with flow

distal through branchial artery and its bifurcation �

Ortho w

ashed out posterior wound (open, com

minuted scapula fracture)

�N

eurosurgical evaluation of nerve trunks �

Closed over JP drain

�A

dmitted to PICU

overnight

�Transferred to floor and drain rem

oved on 8/12

�D

ischarged to inpatient psychiatric unit on 8/14 with neurosurgical follow

-up for neuro deficits

TC

�3 yo F w

ho was shot in the chest w

ith a BB gun by her brother at hom

e (8/2) – traum

a stat

�She w

as seen at an OSH

where she had a CT scan, and w

as found to have a missile

in her heart (images not available)

�PE: 4-5m

m w

ound along left sternal border

�Cardiology and CT surgery w

ere consulted in the ED

�ECH

O : foreign body lodged near the tricuspid valve, avulsed papillary m

uscle w

ith mild tricuspid regurgitation; m

oderate pericardial effusion with RV

collapse

�Taken to CV

suite for fluoroscopic and ultrasound guided evacuation of hem

opericardium and placem

ent of pericardial drain (55 ml blood)

�A

dmitted to CV

ICU

TC: 8/3/15

TC

�8/3: repeat x-ray and ECH

O perform

ed �

Echogenic mass at base of septal leaflet of tricuspid valve consistent w

ith pellet �

Trivial pericardial effusion

�8/4: no signs of tam

ponade, pellet unchanged on imaging

�Transferred to floor

�8/5: repeat ECH

O: BB

pellet in same location, avulsed papillary m

uscle with

tricuspid regurg, normal biventricular size and function

�D

ischarged home

�Cardiology clinic follow

up on 8/14: normal activity w

ithout limitations

�ECH

O: unchanged, no effusion

�Plan for repeat ECH

O and clinic visit in 6 m

onths

TC: 8/5/15

CASE 2012

�6 yo M

, presents as level 1 trauma to N

CH

�Struck in the chest by a projectile ejected from

the underside of a lawnm

ower

�Im

mediately collapsed, question of bystander CPR at the scene

�Taken to a local hospital

�H

R and BP labile on transport from O

SH to N

CH

�A

wake and com

plaining of chest pain on arrival

�Exam

: small puncture w

ound over body of sternum

�Electively intubated

CASE 2012

Pre-intubation

Post-intubation (30 minutes later)

CASE 2012

�FA

ST exam: large pericardial effusion

�Cardiology perform

ed ultrasound guided pericardiocentesis and drain placement

�150 m

l blood aspirated

�H

emodynam

ics improved

�Thoracic CT perform

ed

CASE 2012

CASE 2012

�A

dmitted to PICU

�Traum

a/general surgery, CT surgery, cardiology, IR

�Risks of rem

oval felt to outweigh any potential benefit

�Repeat ECH

O: no accum

ulation of fluid �

No structural or functional cardiac dam

age

�Pericardial drain rem

oved and pt extubated on HD

#2

�D

ischarged on HD

#6

�A

symptom

atic with stable CXR at follow

-up

NCH

REVIEW

�Patients extracted from

trauma registry

�10 year period (Jan 2003-D

ec 2012)

�D

ata collected �

Dem

ographics �

Mechanism

of injury �

GCS, A

IS, ISS �

Diagnoses, procedural inform

ation �

ICU days, total LO

S, ventilator days �

Outcom

e and complications

NCH

REVIEW

�65 patients w

ere found to have penetrating thoracic injuries

�These patients w

ere reviewed and categorized into 2 groupd

�H

igh velocity (GSW

) �

Low velocity (knife stab w

ound)

�There w

ere 7 total fatalities �

All w

ere high velocity wounds

�A

ll patients that underwent CPR, defibrillation or ED

thoracotomy died

NCH

DEM

OG

RAPH

ICS

ALL Low

Velocity H

igh Velocity P-value

Num

ber 65

14 (21.5%)

51 (78.5%)

Age, mean

12.16 (1.33-20) 9.53 (2.42-16)

12.89 (1.33-20) p=0.018*

Male sex

53 (81.5%)

10 (71.4%)

43 (84.3%)

p=0.271

White race

27 (41.5%)

12 (85.7%)

15 (29.4%)

p=0.002*

Private Insur. 20 (30.8%

) 5 (35.7%

) 15 (29.4%

) p=0.903

NCH

REVIEW

All Patients

Low Velocity

High Velocity

p-value

ISS 17 + 14 (1-75)

12 + 7 (1-26) 18 + 16 (1-75)

p=0.331

Total AIS 10 + 7 (1-36)

7 + 5 (1-17) 11 + 7 (1-36)

p=0.090

Initial GC

S 13 + 4 (3-15)

14 + 3 (3-15) 13 + 4 (3-15)

p=0.637

LOS (days)

6.3 + 9.0 (1-45) 3.6 + 2.2 (1-9)

7.1 + 9.9 (0-45) p=0.640

ICU

LOS (days)

1.4 + 4.5 (0-36) 0.6 + 0.7(0-2)

1.6 + 5.1 (0-36) p=0.356

Ventilator Days

0.5 + 1.6 (0-12) 0.1 + 0.4 (0-1)

0.6 + 1.8 (0-12) p=0.152

NCH

REVIEW

: INJU

RIES

�M

ajor vascular injuries occurred in 11 patients (1 low velocity)

�Cardiac injuries identified in 4 patients

�N

eurologic injuries in 7 patients

�Solid organ injuries m

ost comm

only liver, followed by renal injuries

�H

ollow viscus injuries less com

mon

NCH

REVIEW

: MO

ST COM

MO

N IN

JURIES

�H

igh velocity �

Pneumothorax (47.1%

) �

Hem

othorax (41.1%)

�Pulm

onary contusion (35.3%)

�Liver laceration (29.4%

)

�Low

velocity �

Pneumothorax (50%

) �

Liver laceration (28.6%)

�H

emothorax (21.4%

) �

Pulmonary contusion (21.4%

)

NCH

REVIEW

: PROCED

URES

ALL Low

Velocity H

igh Velocity P-value

Transfusion 8 (12.31%

) 2 (14.29%

) 6 (11.76%

) p=1.000

Chest Tube

31 (47.69%)

5 (35.71%)

26 (50.98%)

p=0.477

Intubation 19 (29.23%

) 2 (14.29%

) 17 (33.33%

) p=0.203

CPR/D

efib 7 (10.77%

) 0 (0%

) 7 (13.73%

) p=0.331

OR

ED Thorac O

R C

hest O

R Abd

OR

Other

3 (4.62%

) 10 (15.38%

) 18 (27.69%

) 11 (16.92%

)

0 (0%

) 4 (28.57%

) 2 (14.29%

) 4 (28.57%

)

3 (5.88%

) 6 (11.76%

) 16 (31.37%

) 7 (13.73%

)

p=1.000 p=0.203 p=0.316 p=0.232

PENETRATIN

G TH

ORA

CIC TRAU

MA

�Penetrating thoracic traum

a in children is rare, but on the rise

�4,500 firearm

-related deaths per year in children

�M

ost comm

on complications are from

pericardial tamponade or V

SD

�Positive pericardial blood m

ay not necessitate sternotomy

�A

s evidenced by the last 2 cases presented �

TC clearly had a cardiac injury, without a full thickness penetration (m

ost likely) of the cardiac m

uscular wall

�The case from

2012 also likely had a cardiac injury as the source of entry of the foreign body into the pulm

onary vascular system

�Both patients recovered w

ith pericardial drainage alone

PENETRATIN

G TH

ORA

CIC TRAU

MA

�There is also one institutional review

of patients undergoing either pericardial w

indow for severe chest traum

a �

3 patients with positive pericardial w

indows w

ere successfully treated without

sternotomy, and prom

pted the review (2 blunt, 1 penetrating)

�15%

of the patients had a positive pericardial window

(n=55) �

89% of w

hich (49) had sustained penetrating trauma

�38%

of those patients had non-therapeutic sternotomies

�There w

ere no differences with respect to age, m

echanism of injury, ISS, presenting lab

values, resuscitation fluids, or vital signs �

Penetrating trauma and hem

odynamic instability w

ere positive predictors of therapeutic sternotom

y

Thorson, CM, et al. Journal of Traum

a and Acute Care Surgery, 2012. 72(6): 1518-1524.

PENETRATIN

G TH

ORA

CIC TRAU

MA

�The Thorson paper is not the only one to report high rates of non-therapeutic sternotom

ies �

Has been reported to range from

0-67%

�This m

ethod not applicable to patients that present in extremis or cardiovascular

collapse �

Our patient TC, w

as clearly very stable on presentation �

A coordinated m

ulti-disciplinary effort is required when these treatm

ent modalities are

employed

EMB

OLIZATIO

N

�Foreign body em

bolization is rare

�Em

boli include needles, bullets, and other projectiles

�Risk of a bullet lodging in the vascular system

is only 0.3%

�80%

of emboli are arterial in nature

�M

any foreign bodies that embolize to the pulm

onary tree have been reported �

Many identified post-operatively (cardiac repair perform

ed, but bullet not identified intra-operatively)

�M

ost are left in place �

Most have no significant com

plications �

Biggest risk is infection, erosion, pulmonary necrosis, throm

bosis

CON

CLUSIO

NS

�Penetrating thoracic traum

a in children is rare, but may be increasing

�V

ascular injury from penetrating thoracic injury m

ay be more com

mon than

previously reported

�Cases should be considered on an individual basis, as standard treatm

ents may

not be necessary �

Patients treated non-operatively need close follow-up

�Prevention and education m

ay be the most im

portant factors to try to reduce the incidence of penetrating traum

a in pediatric patients

FUTU

RE STUD

IES

�G

iven the number of significant penetrating thoracic traum

a that presented this sum

mer alone to Le Bonheur, there m

ay be a much larger population in M

emphis

to study

�A

retrospective review m

ay lead to information that could be used for prevention

programs

�A

specific review of both blunt and penetrating vascular traum

a would likely also

yield a larger population than may have been previously reported