commonly affected, with the thoracic region having the highest mortality rate
(approximately 35%).
TABLE 115.1
THORACIC TRAUMA INJURIES REQUIRING OPERATIVE
INTERVENTION
Injury

Signs and symptoms

Tracheal/bronchial
Active chest tube air leak, pneumothorax not resolved
rupture
Lung parenchyma,
Chest tube bleeding greater than 2–3 mL/kg/hr or
internal mammary
hypotension unresponsive to transfusions
artery laceration,
intercostal artery
laceration
Esophageal
Abnormal esophagram (uncontained leak) or
disruption
esophagoscopy
Gastric contents in the chest tube
Diaphragmatic
Abnormal gas pattern in the hemithorax
hernia
Displaced nasogastric tube in the hemithorax
Pericardial
Positive pericardiocentesis
tamponade

Great vessel
Widened mediastinum
laceration
Tracheal or nasogastric tube deviation
Blurred aortic knob
Abnormal CT angiogram
The patient’s signs and symptoms will depend on the region injured. Patients
with an esophageal rupture in the cervical region may complain of neck stiffness
or neck pain. They may regurgitate bloody material and have cervical
subcutaneous emphysema or odynophagia. A lateral neck radiograph may show
retroesophageal emphysema. In the thoracic region, patients may present with
abdominal spasms and guarding, chest pain, subcutaneous emphysema,


tachycardia, or dyspnea. A CXR may show a pneumothorax,
pneumomediastinum, subcutaneous emphysema in the neck, a left pleural
effusion, or an air–fluid level in the mediastinum. Perforation of the intraabdominal esophagus may cause retrosternal, epigastric, or shoulder pain.
Patients with suspected esophageal perforation should be adequately volume
resuscitated and receive antibiotics covering gram-positive, gram-negative, and
anaerobic organisms. The diagnosis of an esophageal perforation can be made by
either an esophagram, esophagoscopy, or both. In one study, flexible
esophagoscopy had a sensitivity of 100% and specificity of 96%. Depending on
the expertise at each institution and the stability of the patient, these studies may
be paired to lessen the chance of a misdiagnosis. Once the diagnosis is made, if
the leak is large and not contained, prompt surgical correction is mandatory.
Smaller, contained leaks may be successfully managed nonoperatively. If the
diagnosis is made within 24 hours, mortality rate is approximately 5%. Delayed
diagnosis for more than 24 hours after injury is associated with a mortality rate of
70%.


DIAPHRAGMATIC INJURIES
A crushing abdominal force will produce a sudden increase in intrathoracic and
intra-abdominal pressure against the fixed diaphragm. A diaphragmatic injury
should also be suspected in any thoracic or upper abdominal penetrating injury.
The level of the diaphragm fluctuates greatly with respirations, and injuries of the
diaphragm have been reported with penetrating wounds as high as the third rib
and as low as the 12th rib. Blunt traumatic diaphragmatic rupture is more
commonly left sided (80%) because the left diaphragm is relatively unprotected
compared to the right, though right and bilateral diaphragmatic injuries have been
reported ( Fig. 115.11 ). Right-sided diaphragmatic injuries are associated with
increased mortality rate as these patients usually have a greater physiologic insult
and associated injuries.


FIGURE 115.11 This 5-year-old boy was on a snowmobile when it crashed into a tree. Initially
there was no respiratory distress, but upon arrival at the emergency department, the patient
became tachypneic and required oxygen. Breath sounds were reportedly normal. Chest
radiograph showed a left-sided diaphragmatic hernia. This injury was surgically repaired in the
operating room, and the patient did well postoperatively.

Motor vehicle collisions are the most common mechanism of injury. The
direction of impact may play a role in the side and type of diaphragmatic rupture.
A lateral torso impact has been shown to be three times more likely to result in a
ruptured diaphragm than a frontal impact and the rupture tends to be on the same
side as the impact. Associated injuries such as pulmonary contusions, hepatic or
splenic lacerations, and fractures of the extremities are present in more than 75%
of patients. Thoracic aortic injuries have been reported in up to 10% of adults
with diaphragmatic injury and should be considered in children with
diaphragmatic trauma.
Patients may present with respiratory distress and have a scaphoid abdomen,

although they are more likely to be symptomatic from associated injuries than
from the diaphragmatic rupture itself. The verbal child may complain of chest


pain or ipsilateral shoulder pain. The presence of bowel sounds within the
thoracic cavity is nonspecific because bowel sounds can be transmitted from the
abdominal cavity in children. More commonly, bowel sounds are absent because
of the ileus that is typically associated with the injury. A nasogastric tube may be
difficult to pass in patients with a diaphragmatic injury and gastric herniation. In
left-sided diaphragmatic tears, the tip of the nasogastric tube may be seen looping
into the chest. Even though the diagnosis of diaphragmatic injury is usually made
upon initial review of the CXR, some series have reported that up to 30% to 50%
of initial films are normal. Right-sided diaphragmatic injury and herniation is
more difficult to diagnose because the herniated organs are more likely to be
solid. The chest x-ray may just show opacification of the right lung fields. This
emphasizes the importance of serial evaluations and CXRs in patients suspected
of having a diaphragmatic injury. Other diagnostic studies such as chest and
abdominal CT scan with contrast or upper and lower gastrointestinal tract series
can help confirm the diagnosis.
Before performing a tube thoracostomy for a pneumothorax or hemothorax,
diaphragmatic injury should be considered to avoid injury to herniated intraabdominal organs. In patients who clinically appear to have a diaphragmatic
injury (scaphoid abdomen, bowel sounds auscultated in the thoracic cavity), a
finger should be inserted in the thoracostomy incision site and the diaphragm
should be palpated before placing a chest tube.
Herniation and strangulation of bowel may result from a delayed diagnosis.
Diaphragmatic defects will not spontaneously heal because of motion associated
with respirations and cyclical tension. Exploratory laparotomy or laparoscopy
should be performed in cases where a diaphragmatic hernia is strongly suspected.

TRAUMATIC ASPHYXIA

Traumatic asphyxia results from direct compression of the chest or abdomen. The
most common mechanism is a child run over by a slowly moving motor vehicle
or pinned underneath a heavy object. In anticipation of impending injury, the
child may inspire, tensing the thoracoabdominal muscles and closing the glottis.
Traumatic asphyxia also occurs in patients with asthma, seizures, persistent
vomiting, and pertussis.
Positive pressure is transmitted to the mediastinum, and blood is forced out of
the right atrium into the valveless venous and capillary systems. The clinical
manifestations occur because the increase in pressure dilates the capillary and
venous systems. Areas drained by the superior vena cava are particularly affected,
explaining the marked difference between the patient’s head and neck as opposed