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Ann Thorac Surg 1996;61:1501-1505
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Penetrating Thoracic Trauma in a Pediatric Population

Boston City Hospital, Boston University Medical Center, Boston, Massachusetts

Accepted for publication January 29, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Introduction. Penetrating thoracic trauma in the pediatric population is increasing at an alarming rate. We sought to describe this population and to define prognostic factors that might be of benefit in the management of these patients.

Methods. We retrospectively reviewed the charts and trauma registry records of 65 patients 18 years of age and younger admitted to an urban level I trauma center with the diagnosis of penetrating thoracic trauma.

Results. The majority of the patients were adolescent boys. Injury severity score greater than 25 and a corrected admission pH less than 7.3 were associated with higher mortality and increased need for surgical intervention. Isolated thoracic injury was found to be associated with a high mortality rate. Autotransfused blood was used in 9 of the 65 patients.

Conclusions. Injury severity score and corrected admission pH are independent predictors of mortality and need for operation in the pediatric population with penetrating chest injuries. Penetrating thoracic wounds demand special attention by the trauma team. The use of autotransfusion may be beneficial in pediatric trauma victims.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Penetrating thoracic wounds are a challenge to the trauma surgeon and often carry a high mortality rate [1]. Recent advances in the diagnosis and management of such injuries has improved the outcome in adult patients. These advances include prehospitalization recognition of significant intrathoracic injury, the use of autotransfusion, and prompt referral to skilled thoracic surgeons. Although data have accumulated for adult patients, little attention has been given to thoracic injury in children. Increases in the incidence of penetrating trauma to children have been documented, but definitive data on this issue are lacking [1–8].

Trauma is the leading cause of death and long-term disability in the pediatric population. Recent studies have shown that mortality due to thoracic trauma was greater than for abdominal trauma, and thoracic trauma was second only to head injuries as a cause of death in children [2]. Most large series have reported blunt chest trauma as the major contributor to pediatric morbidity and mortality [3–5]. However, the recent increase in penetrating thoracic trauma in children has been associated with higher mortality rates than those reported after blunt injury [1]. The availability and access to firearms coupled with the psychosocial and socioeconomic difficulties of childhood and adolescence have been suggested as risk factors for penetrating trauma [5]. Despite the obvious public health concern of this issue, there are few objective data on the demographics and management of these patients [1–8].

Recent reviews of penetrating trauma in the pediatric population have addressed some of the social and economic concerns of children who were injured by gunshot wounds (GSWs) [1, 4, 5]. The clinical management and outcome of isolated penetrating thoracic injury has received little attention [6, 7]. Prognostic factors affecting the management of these children have not been identified. The adult literature has suggested that the injury severity score (ISS) in conjunction with emergency department admission pH may be predictors of mortality and necessity of surgical intervention [8, 9]. The use of a corrected admission pH (CpH) has also been shown to be an independent predictor of mortality and need for surgical management in the adult population [10]. We sought to determine if these factors affected outcome or predicted which patients required operative intervention in pediatric patients with penetrating thoracic trauma.

The use of autotransfusion devices to replace autologous blood in patients with significant hemothorax has been proven to be of benefit in adult trauma patients [11–15]. The use of these devices in children has been described, but clear survival benefit has not been shown [16]. Although autotransfusion has been available for many years, it is not used as commonly as in adult patients. We thus hoped to obtain some preliminary information regarding the benefits of autotransfusion in pediatric patients sustaining thoracic trauma.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
From July 1, 1992, through June 30, 1994, 65 patients aged 18 and younger were admitted with a diagnosis of penetrating thoracic trauma to Boston City Hospital, a large urban level I trauma center. In the same 2-year period there were approximately 3,600 pediatric admissions, and 703 pediatric trauma admissions through our emergency room. Ninety-two percent of pediatric thoracic trauma victims were male, with a mean age of 16 years. Fifty-five percent sustained stab wounds (SWs) and 45% sustained GSWs. Forty-five patients (69%) sustained isolated chest injuries, whereas 20 (31%) incurred additional extrathoracic injuries.

Patient hospital records and a trauma registry were used in obtaining data for admission through discharge status. Data examined included mechanism and pattern of injury, age, sex, length of hospital stay, admission pH, admission CO₂, ISS, use of autotransfused blood, need for surgical intervention, and final outcome. A CpH for a standardized CO₂ tension of 40 mm Hg was derived using the following formula: CpH = pH + (40 - CO₂) x 0.008. This formula was used for all patients in whom both admission pH and CO₂ data were available [10].

Injury severity score is an anatomic injury grading system used to summarize multiple traumatic injuries, first derived by Baker and associates [8]. The ISS is derived from the abbreviated injury scale (AIS), in which a value from 1 to 6 is assigned to each injury. Minimal injuries are assigned an AIS 1 value, whereas nearly always fatal injuries are assigned an AIS 6 value. The ISS score is calculated from the sum of the squares of the highest AIS score assigned to the three most severely injured body regions (head/neck, face, chest, abdomen and pelvis, extremities and external). In cases where a patient sustains an injury assigned an AIS 6, the ISS is assigned the highest value possible (75) and all other injuries are disregarded in the calculation. When lesser injuries are sustained, the ISS is calculated for each body area injured and the three largest values are area summed. For example, a patient sustaining isolated thoracic injuries including an aortic laceration (AIS 5) and a rib fracture (AIS 2) would have an ISS of 25 for the chest region and a total ISS of 25 (only the most severe injury in this body area is used in the calculation). The addition of a ruptured spleen (AIS 2) in such an individual would result in an ISS of 29 (25 from the chest and 4 from the abdomen). The same principle is used for additional injuries.

Student's t test was used to test the difference in age, length of stay, admission pH, and ISS between patients with GSWs and SWs. The ² test was used to determine association between CpH or ISS and mortality or need for surgical intervention. The ² test was also used to determine association between final outcome and injury mechanism and presence of extrathoracic wounds.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The average age of patients sustaining both SWs and GSWs was 16 years. The mean admission pH was slightly lower for GSWs (7.29) than for SWs (7.31). The median ISS was significantly greater (p 0.001) for GSWs (18)than for SWs (9). The average length of hospital stay for both groups was 5 days.

Patient outcomes were categorized at discharge as returning to preinjury capacity, leaving with temporary handicap, transfer to a long-term rehabilitation facility, leaving against medical advice, and death (Table 1). There was a significantly higher mortality rate (p < 0.01) associated with GSWs.

CpH was calculated for patients whose admission pH and serum CO₂ data were available. The CpH was compared with outcomes and need for operation. For patients sustaining GSW injuries, 8 of 10 (80%) with CpH less than 7.3 required operation and 3 of the 10 (30%) died. Four of 11 (36%) with CpH greater than 7.3 required operation, and there were no deaths. For patients sustaining SW injuries, 7 of 11 (64%) with CpH less than 7.3 required operation, and 1 of 11 (9%) died. Three of 16 (19%) with CpH greater than 7.3 required operation, and there were no deaths. The CpH was a significant predictor of the need of surgical intervention (p < 0.01 for both GSWs and SWs) and of mortality for patients with either GSW or SW injuries.

Isolated chest injuries represented the majority of our patient's injuries (45); however, almost a third (20) of the patients sustained injuries to other areas of the body (Table 2). The mean length of hospital stay was significantly longer (p = 0.001) for those patients sustaining additional extrathoracic wounds (10 days) than for those sustaining isolated thoracic injuries (3 days). Outcomes are shown in Table 3. As seen, the presence of extrathoracic wounds contributed to a slightly greater disability (p = 0.001), but not to mortality. Deaths were due to intrathoracic injuries alone in 10 of 11 patients and due to fatal cardiac and brain injury in 1 patient:

Autotransfused blood was used in the treatment of 9 of the 65 patients (Fig 1). The median ISS for those autotransfused (25) was significantly greater (p = 0.03) than for those not receiving autotransfusion (9). There was no significant difference in the length of hospital stay (7 days for both) in either group. When a group of patients with the most severe injuries (ie, ISS 25) was considered, 2 of 6 (33%) of the autotransfused group died and all 6 required surgical intervention, whereas of the nonautotransfused group, 9 of 15 (66%) died, and 7 of the 15 required operation.

View larger version (17K): [in this window] [in a new window]   Fig 1. . Comparison of patients who received an autotransfusion (white bars) and those who did not (black bars). Autotransfused blood may decrease mortality in selected patients. (AVG = average; GSW = gunshot wound; ISS = injury severity score.)

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

The majority of patients included in this analysis are more properly referred to as adolescents rather than children. Peterson and associates [17] have suggested that the analysis of pediatric penetrating trauma should separate children from adolescents. Discrepancy in the actual age cutoff between childhood and adolescence currently exists in studies of pediatric trauma. Ranges between 12 and 16 years have been used in other reports with few available data in younger patients [1, 3, 5–7, 17]. The infrequency of patients less than 12 years old in our data set and current controversy as to an accurate age cut-off to represent pediatric patients required us to examine all patients aged less than 18 years. This population, although not truly ``pediatric,'' may represent the patient population seen by the pediatric trauma surgeon.

The lack of guidelines in the management of pediatric thoracic trauma suggests the need for identifying simple indicators of more severe injury. The use of trauma scoring and specific physiologic variables, such as admission pH, have been shown to be beneficial in the adult penetrating trauma population. Recent evidence has suggested that base deficit, the ISS, and revised trauma score are good predictors of mortality in the adult population [8–10]. Baker and colleagues [8], who developed the ISS, have shown that it can be used to predict which patients are at higher risk of mortality and need more immediate care. More recently, it has been shown that the ISS and CpH are independent predictors of mortality and requirement of surgical intervention in both blunt and penetrating trauma in adults [10].

In our experience with a pediatric population who sustained mostly thoracic wounds, we found that mortality occurred only in those patients with an ISS of 25 or greater. Sixty-nine percent of GSW patients with ISS of 25 or greater died, whereas only 2 of 8 (25%) SW patients in this category died. The ISS was found to be a significant independent predictor of mortality in both GSW and SW patients, but was better for GSW patients. As a predictor of surgical requirement, the ISS was found to be significant for SWs, but not for GSWs. This discrepancy may be due to the fact that those severely injured by firearms died before any surgical intervention was attempted.

Our experience also shows that the CpH is an independent predictor of both mortality and requirement for surgical intervention. When a cutoff CpH of 7.3 is considered, we found that there were no deaths of patients with a CpH above that level, whereas there was a small but significant mortality rate for those patients with a lower CpH. The CpH was a significant predictor of the need for surgical intervention in both patients with SWs and GSWs. It seems important for all pediatric patients with penetrating thoracic trauma to have arterial blood gases drawn in the emergency room to aid in the clinical decision-making process.

Although most of our patients suffered isolated thoracic wounds, almost a third were also injured in another body area. We found that although there was no significant difference in mortality between the two groups of patients, those patients who sustained extrathoracic wounds had a significantly longer hospital stay and were more likely to be discharged with a temporary physical or psychological disability. Furthermore, the absence of severe thoracic trauma (ISS of chest <25) was seen in most survivors. This seems to imply that although extrathoracic wounds contributed significantly to morbidity, mortality was directly related to the presence of severe thoracic injury in almost all cases.

Autotransfusion has been used in adult trauma situations for the last few decades. It has been shown to be safe and economical, and it possesses many desirable advantages over homologous blood [13, 16]. Indications for autotransfusion of the adult patient have been suggested: an initial hematocrit less than 35%, greater than 2 L of crystalloid resuscitation, or a hemothorax of at least 500 mL have been suggested as indications for autotransfusion [11, 14]. Recently, Kharash and colleagues [16] reviewed 3 cases of pediatric patients being partially resuscitated with autotransfused blood. They suggest that autotransfusion should be used early in pediatric trauma cases, and that transfusion volumes smaller than 500 mL may be beneficial. Although previous reports have stressed the need for autotransfusion capabilities in the emergency room, they have not addressed the effect on survival.

Of our 65 patients, 9 received autologous transfusions. Children with severe thoracic trauma who survive long enough to be seen in the emergency room are candidates for autotransfusion, when indicated. The numbers of children treated with autotransfused blood in this study was too small to provide meaningful results. Reasons for the limited use of autotransfused blood include minimal or delayed chest tube drainage and lack of recognition of autotransfusion candidates in the emergency room. This remains an important area of care in the pediatric patient with penetrating thoracic trauma, and further research is needed to quantify the benefit of autotransfusion.

The increasing incidence of penetrating trauma in children has become a major public health issue in the United States. The increased availability of handguns and the turbulent psychosocial development issues in adolescence have been suggested as factors influencing this trend. The few large series that have examined patterns of GSWs have suggested that children are most likely to be injured by an acquaintance or relative. Twenty million homes report having guns, of which 6 million report having handguns. These statistics suggest that prevention is the best method for reducing pediatric mortality from penetrating injuries. While society is beginning to address this issue, the emergency department continues to see an increasing number of penetrating injuries in children.

This study has provided an analysis of parameters associated with outcomes in pediatric penetrating thoracic trauma. These data suggest that the ISS and emergency department CpH are good indicators of the indications of the need for operative intervention and of mortality. We were able to confirm the seriousness of isolated thoracic injury and showed that extrathoracic injury only increases morbidity, but not mortality. The use of autotransfusion devices in children with significant hemothoraces may be beneficial, but further prospective studies need to be done.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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11. Jorden RC. Penetrating chest trauma. Emerg Med Clin North Am 1993;11:97–105.[Medline]
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13. Van Way CW III. Advance techniques in thoracic trauma. Surg Clin North Am 1989;69:143–55.[Medline]
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17. Peterson RJ, Tepas JJ, Edwards FH, Kissoon N, Pieper P, Ceithaml EL. Pediatric and adult thoracic trauma: age-related impact on the presentation and outcome. Ann Thorac Surg 1994;58:14–8.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Reinhorn, M. Articles by Millham, F. H. Search for Related Content PubMed PubMed Citation Articles by Reinhorn, M. Articles by Millham, F. H.