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Post-traumatic pulmonary contusion in children
ORIGINAL CONTRIBUTION pulmonary contusion, pediatric
Post-Traumatic Pulmonary Contusion in Children We reviewed 35 consecutive cases of post-traumatic pulmonary contusion in children that occurred during a 12-year period. Of these, 19 children (54%) were more than 5 years old, 30 (86%) were involved in motor vehicle accidents, and 29 (83%) had multiple trauma. External thoracic wall contusion, fracture of the bony thorax, tachypnea, hemoptysis, and abnormal breath sounds were frequently absent on presentation. Associated intrathoracic lesions of pleural effusion, pneumothorax, and hemothorax occurred in 20 children (57%) and were particularly prevalent in those with fracture of the bony thorax (93%); the radiographic appearance of these lesions was delayed up to 48 hours in 40% of cases. In 34 children (97%), radiographic evidence of pulmonary contusion was present on admission and did not progress radiographically during hospitalization. No child experienced respiratory deterioration subsequent to presentation or required mechanical ventilation for respiratory insufficiency. Pulmonary contusion in children is usually a consequence of significant-impact injury associated with multiple trauma and has a good prognosis. Despite a paucity of abnormal physical findings, children who sustain high-impact trauma should receive radiographic evaluation of the chest to assess for possible intrathoracic injury. When pulmonary contusion is accompanied by fracture of the bony thorax, serial radiographic evaluation of the chest should be performed during the initial 48 hours of hospitalization. [Bonadio WA, Hellmich T: Post-traumatic pulmonary contusion in children. Ann Emerg Med October 1989;18:1050-1052.]
William A Bonadio, MD Thomas Hellmich, MD Milwaukee, Wisconsin From the Department of Pediatrics, The Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee. Received for publication February 6, 1989. Revision received June 19, 1989. Accepted for publication July 5, 1989. Address for reprints: William A Bonadio, MD, Department of Pediatrics, Children's Hospital of Wisconsin, EDTC Room 127, 9000 W Wisconsin Avenue, Milwaukee Wisconsin 53201.
INTRODUCTION Thoracic injury in childhood occurs most commonly with blunt trauma due to automobile accidents. 1 4 A potentially serious complication of thoracic trauma is pulmonary contusion. No previous study has been performed of children who sustain post-traumatic pulmonary contusion; we review the characteristics and outcome of a series of children who experienced this type of injury. METHODS We reviewed the medical records of patients with a discharge diagnosis of pulmonary contusion at the Children's Hospital of Wisconsin, Milwaukee, from 1976 to 1988. All patients had a chest radiograph on presentation. The extent of pulmonary contusion was assessed by a pediatric radiologist reviewing admission and successive radiographs of the chest made during hospitalization. RESULTS During the 12-year period, there were 35 children with a discharge diagnosis of pulmonary contusion. Patients' ages ranged from 2 months to 18 years, with four less than 2 years old, 12 who were 2 to 5 years old, 16 who were 5 to 10 years old, and three more than 10 years old. There were 20 boys and 15 girls; racial distribution included 20 whites, 13 blacks, and two Hispanics. All patients were hospitalized~ 27 were treated in an ICU during the initial 48 hours of treatment. The clinical characteristics of these patients are shown (Table). Extrathoracic injury involving another major organ system occurred in 29 pa-
18:10 October 1989
Annals of Emergency Medicine
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PULMONARY CONTUSION Bonadio & Hellmich
tients. Arterial blood gas analysis was performed in room air at the time of admission in 17 patients; 12 had PaO 2 less than 90 m m Fig (five had PaO 2 less than 50 m m Hg}. Of the 12 patients with documented hypox(a, six had an intrathoracic lesion o t h e r than p u l m o n a r y c o n t u s i o n (pleural effusion in four patients and pneumothorax in two patients), and five had a n admission respiratory rate of less than 30 breaths per minute. Supplementa ! oxygen therapy was received by 27 patients. In no patient was mechanical ventilation required for r e s p i r a t o r y i n s u f f i c i e n c y , although five patients were mechanically ventilated due to severe head injury requiring hyperventilation. Also, in no patient did clinical deterioration in respiratory status occur during the course of hospitalization. Of 22 patients not mechanically ventilated who received oxygen supplementation, therapy was discontinued after a mean of 1.8 days. All patients survived. Results of admission radiographs revealed pulmonary contusion in 34 patients; one other patient developed radiographic evidence of contusion six hours after a normal initial chest radiograph. The maximum extent of contusion involved less than three lobes in 26 patients and three or more lobes in nine. In each case, repeat radiograph of the chest was performed during the initial 48-hour period of hospitalization; in no instance was there extension of contusion.- All patients had radiographic evidence of partial or complete resolution of the contusion before discharge. Associated i n t r a t h o r a c i c lesions occurred in 20 patients. Two patients with h e m o t h o r a x had radiographic evidence of fluid collection in the pleural cavity, with drainage of blood noted on chest tube insertion. Of 14 other patients with radiographic evid e n c e of fluid c o l l e c t i o n in the pleural space, ten had n o n b l o o d y fluid obtained on chest tube insertion (considered pleural effusionl; the other four patients did not receive surgical interventioi~ to further delineate the character of the fluid present. All intrathoracic lesions were radiographically identified within the initial 48-hour period; in eight patients accounting for nine instances of pleural effusion, five instances of 50/1051
TABLE. Clinical characteristics of children with pulmonary contusion Parameter
No. of Patients
Traumatic Event Motor vehicle-pedestrian collision Crush injury Fall Presenting Clinical Features Respiratory rate (breaths/min) < 20 20 - 30 3O - 4O > 40 Abnormal breath sounds Cyanosis Hemoptysis Extrathoracic Lesions Neurologic Skull fracture Intracranial lesion* Abdominal* Hepatic lesion Renal lesion Splenic lesion Orthopedic Long-bone fracture Pelvic fracture Thoracic Wall Lesions Dermal contusion-abrasion Rib fracture Clavicle fracture Scapula fracture Intrathoracic Lesions Pleural effusion Pneumothorax Hemothorax Flail chest Great-vessel injury *Lesion present on computed tomography scan. tFour cases with unspecified pleural fluid collection on radiograph.
pneumothorax, and two instances of hemothorax, lesions were not present on admission radiograph. Of 15 patients with fractures of the bony thorax, 14 experienced at least one of these a s s o c i a t e d i n t r a t h o r a c i c lesions. DISCUSSION Trauma is the most common cause of death in children more than 1 year old. Up to 30% of traumatized children sustain injuries to the thorax,S, 6 with an associated m o r t a l i t y rate ranging from 7% to 14% in older children and up to 25% in children less than 5 years old. 4,6 Pulmonary Annals of Emergency Medicine
30 3 2
3 16 10 6 16 2 0
12 5 10 5 2 23 3 16 10 4 1 14t 10 2 0 0
contusion, defined as injury to lung parenchyma with edema and interstitial hemorrhage, is frequently associated w i t h severe b l u n t t h o r a c i c trauma. It is a disorder capable of progressing to respiratory insufficiency due to ventilation-perfusion abnormalities resulting from disruption of the alveolar-capillary interface.7,8 In contrast with a previous survey of pediatric thoracic trauma, 9 we observed that the majority of children with pulmonary contusion secondary to blunt thoracic trauma were more than 5 years old. In accordance with previous reports,>4, 9ql 90% of chil18:10 October 1989
dren i n our series were v i c t i m s of motor v e h i c l e - r e l a t e d accidents. Also in accord w i t h previous findings, T M we noted that the majority of these c h i l d r e n (more t h a n 80%) experienced m u l t i p l e trauma and had an a c c o m p a n y i n g i n j u r y to at least one other major organ system, underscoring the significant-impact nature of the traumatic event. The a b s e n c e of signs of e x t e r n a l chest w a l l i n j u r y a n d r e s p i r a t o r y compromise on i n i t i a l e x a m i n a t i o n was c o m m o n i n c h i l d r e n w i t h pulm o n a r y c o n t u s i o n . As i n d i v i d u a l variables, t h e a n t i c i p a t e d c l i n i c a l f i n d i n g s of t a c h y p n e a , a b n o r m a l breath sounds, external thoracic wall contusion, and fracture of the b o n y thorax w e r e each a b s e n t i n m o r e than 50% of p a t i e n t s w i t h p u l m o nary contusion. The absence of these abnormalities on p r e s e n t a t i o n does not preclude u n d e r l y i n g injury to the lung. The radiographic features of children with p u l m o n a r y c o n t u s i o n were varied and dynamic. Of note was that in almost every instance, the full radiographic e x t e n t of c o n t u s i o n was present at the t i m e of a d m i s s i o n . This, c o m b i n e d with the finding that no patient experienced clinical deterioration i n respiratory status after initial p r e s e n t a t i o n , w o u l d seem to conflict w i t h the claim that pulmonary c o n t u s i o n progresses c l i n i c a l l y to its m a x i m u m extent by the second or t h i r d day a f t e r t h e t r a u m a t i c event. 12 The majority of children w i t h pulmonary c o n t u s i o n did not experience fracture of the bony thorax. In contrast w i t h the findings of a previous series of adults w i t h b l u n t thoracic trauma in which more than 70% experienced fractures of the bony thorax, u we found only 40% of children with this type of associated injury; specifically, o n l y 28% e x p e r i e n c e d rib fracture. As opposed to reports that d o c u m e n t e d flail chest in nearly 0ne-fourth of adults with b l u n t tho-
18:10 October 1989
racic trauma, m, n no instance of this c o m p l i c a t i o n occurred in any child in our series. Both the lower rate of rib fracture and absence of flail chest in children m a y be a reflection of the greater elasticity of the pediatric cartilaginous and bony skeleton. Intrathoracic lesions associated w i t h p u l m o n a r y c o n t u s i o n occurred in a p p r o x i m a t e l y 60% of p e d i a t r i c cases. P n e u m o t h o r a x , u s u a l l y cited as the most c o m m o n complication of pediatric thoracic injury, 13 occurred with less frequency than did pleural effusion-hemothorax. In accord with p r e v i o u s reports,9, lo a l m o s t all instances of p u l m o n a r y c o n t u s i o n w i t h rib f r a c t u r e were a s s o c i a t e d w i t h pneumothorax and/or pleural e f f u s i o n - h e m o t h o r a x . The radiographic appearance of these associated lesions was c o m m o n l y delayed up to 48 hours after the appearance of p u l m o n a r y c o n t u s i o n . T h e presence of rib fracture in a child with b l u n t thoracic trauma should heighten awareness for the possible developm e n t of o n e of t h e s e p o t e n t i a l l y treatable underlying complications and warrant serial radiographic evaluation. The o u t c o m e of these children was u n i f o r m l y good. N o c h i l d experienced respiratory insufficiency, w h i c h c o n t r a s t s w i t h p r e v i o u s reportslO, H, 14 i n w h i c h up to 40% of adult p a t i e n t s w i t h p u l m o n a r y cont u s i o n required assisted v e n t i l a t i o n . Although only about one-half of all p a t i e n t s received arterial blood gas analysis, the m a j o r i t y exhibited hyp o x e m i a - y e t m o s t c h i l d r e n required only supportive care and experienced an u n c o m p l i c a t e d clinical course w i t h regard to respiratory status. CONCLUSION P u l m o n a r y c o n t u s i o n i n children is u s u a l l y a s s o c i a t e d w i t h signific a n t - i m p a c t t r a u m a and has a good prognosis. Despite a paucity of abnorm a l c l i n i c a l f i n d i n g s , all c h i l d r e n
Annals of Emergency Medicine
who sustain injuries from highi m p a c t or c r u s h i n g - t y p e t r a u m a should receive radiographic evaluation of the chest to assess for possible i n t r a t h o r a c i c injury. W h e n pulm o n a r y c o n t u s i o n is associated with fracture of the bony thorax, serial radiographic e v a l u a t i o n of the chest should be performed during the subs e q u e n t 48 hours of h o s p i t a l i z a t i o n to m o n i t o r for delayed onset of complications.
REFERENCES
1. Bellinger SB: Penetrating chest injuries in children. Ann Thorac Surg 1972;14:635-644. 2. DougallAM, Paul ME, FinleyRJ, et al: Chest trauma - Current morbidity and mortality. I Trauma 1977;17:547-553. 3. LevyJL: Managementof crushing injuries in children. South Med I 1972;65:1040-1044. 4. Smyth BT: Chest trauma in children. J Pediatr Surg 1979;14:41-46. 5. Vclcek FT, Weiss A, DiMaio D, et al: Traumatic death in urban children. J Pediatr Surg 1977;12:375-379. 6. SinclairMC, Moore T: Major surgery for abdominal and thoracic trauma in childhood and adolescence. J Pediatr Surg 1974;9:155-158. 7. Ratliff JL, Fletcher JR, KoprivaCJ, et al: Pulmonary contusion: A continuing management problem. J Thorac Cardiovasc Surg 1971;62: 638-644. 8. Hankins JR, Attar S, Turney SZ, et al: Differential diagnosis of pulmonary parenchymal changes in thoracic trauma. A m Surg 1973; 39:309-318. 9. MellerJL, Little AG, Shermeta DW: Thoracic trauma in children. Pediatrics 1984;74:813-819. 10. Johnson JA, Cogbill TH, Winga ER: Determinants of outcome after pulmonarycontusion. J Trauma 1986;26:695-697. 11. Schorr RM, Crittenden M, Indeck M, et al: Blunt thoracic trauma: Analysisof 515 patients. Ann Surg 1987;206:200-205. 12. Williams JR, Bonte FJ: Pulmonary changes in non-penetratingthoracic trauma. Texas State Med J 1963;59:27-30. 13. Eichelberger MR, Randolph JG: Thoracic trauma in children. Surg Clin North Am 1981; 61:1181-1198. 14. Clark GC, Schecter WP, Trunkey DD: Variables affecting outcome in blunt chest trauma: Flail chest vs pulmonary contusion. J Trauma 1988;28:298-304.
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Post-Traumatic Pulmonary Contusion in Children We reviewed 35 consecutive cases of post-traumatic pulmonary contusion in children that occurred during a 12-year period. Of these, 19 children (54%) were more than 5 years old, 30 (86%) were involved in motor vehicle accidents, and 29 (83%) had multiple trauma. External thoracic wall contusion, fracture of the bony thorax, tachypnea, hemoptysis, and abnormal breath sounds were frequently absent on presentation. Associated intrathoracic lesions of pleural effusion, pneumothorax, and hemothorax occurred in 20 children (57%) and were particularly prevalent in those with fracture of the bony thorax (93%); the radiographic appearance of these lesions was delayed up to 48 hours in 40% of cases. In 34 children (97%), radiographic evidence of pulmonary contusion was present on admission and did not progress radiographically during hospitalization. No child experienced respiratory deterioration subsequent to presentation or required mechanical ventilation for respiratory insufficiency. Pulmonary contusion in children is usually a consequence of significant-impact injury associated with multiple trauma and has a good prognosis. Despite a paucity of abnormal physical findings, children who sustain high-impact trauma should receive radiographic evaluation of the chest to assess for possible intrathoracic injury. When pulmonary contusion is accompanied by fracture of the bony thorax, serial radiographic evaluation of the chest should be performed during the initial 48 hours of hospitalization. [Bonadio WA, Hellmich T: Post-traumatic pulmonary contusion in children. Ann Emerg Med October 1989;18:1050-1052.]
William A Bonadio, MD Thomas Hellmich, MD Milwaukee, Wisconsin From the Department of Pediatrics, The Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee. Received for publication February 6, 1989. Revision received June 19, 1989. Accepted for publication July 5, 1989. Address for reprints: William A Bonadio, MD, Department of Pediatrics, Children's Hospital of Wisconsin, EDTC Room 127, 9000 W Wisconsin Avenue, Milwaukee Wisconsin 53201.
INTRODUCTION Thoracic injury in childhood occurs most commonly with blunt trauma due to automobile accidents. 1 4 A potentially serious complication of thoracic trauma is pulmonary contusion. No previous study has been performed of children who sustain post-traumatic pulmonary contusion; we review the characteristics and outcome of a series of children who experienced this type of injury. METHODS We reviewed the medical records of patients with a discharge diagnosis of pulmonary contusion at the Children's Hospital of Wisconsin, Milwaukee, from 1976 to 1988. All patients had a chest radiograph on presentation. The extent of pulmonary contusion was assessed by a pediatric radiologist reviewing admission and successive radiographs of the chest made during hospitalization. RESULTS During the 12-year period, there were 35 children with a discharge diagnosis of pulmonary contusion. Patients' ages ranged from 2 months to 18 years, with four less than 2 years old, 12 who were 2 to 5 years old, 16 who were 5 to 10 years old, and three more than 10 years old. There were 20 boys and 15 girls; racial distribution included 20 whites, 13 blacks, and two Hispanics. All patients were hospitalized~ 27 were treated in an ICU during the initial 48 hours of treatment. The clinical characteristics of these patients are shown (Table). Extrathoracic injury involving another major organ system occurred in 29 pa-
18:10 October 1989
Annals of Emergency Medicine
1050/49
PULMONARY CONTUSION Bonadio & Hellmich
tients. Arterial blood gas analysis was performed in room air at the time of admission in 17 patients; 12 had PaO 2 less than 90 m m Fig (five had PaO 2 less than 50 m m Hg}. Of the 12 patients with documented hypox(a, six had an intrathoracic lesion o t h e r than p u l m o n a r y c o n t u s i o n (pleural effusion in four patients and pneumothorax in two patients), and five had a n admission respiratory rate of less than 30 breaths per minute. Supplementa ! oxygen therapy was received by 27 patients. In no patient was mechanical ventilation required for r e s p i r a t o r y i n s u f f i c i e n c y , although five patients were mechanically ventilated due to severe head injury requiring hyperventilation. Also, in no patient did clinical deterioration in respiratory status occur during the course of hospitalization. Of 22 patients not mechanically ventilated who received oxygen supplementation, therapy was discontinued after a mean of 1.8 days. All patients survived. Results of admission radiographs revealed pulmonary contusion in 34 patients; one other patient developed radiographic evidence of contusion six hours after a normal initial chest radiograph. The maximum extent of contusion involved less than three lobes in 26 patients and three or more lobes in nine. In each case, repeat radiograph of the chest was performed during the initial 48-hour period of hospitalization; in no instance was there extension of contusion.- All patients had radiographic evidence of partial or complete resolution of the contusion before discharge. Associated i n t r a t h o r a c i c lesions occurred in 20 patients. Two patients with h e m o t h o r a x had radiographic evidence of fluid collection in the pleural cavity, with drainage of blood noted on chest tube insertion. Of 14 other patients with radiographic evid e n c e of fluid c o l l e c t i o n in the pleural space, ten had n o n b l o o d y fluid obtained on chest tube insertion (considered pleural effusionl; the other four patients did not receive surgical interventioi~ to further delineate the character of the fluid present. All intrathoracic lesions were radiographically identified within the initial 48-hour period; in eight patients accounting for nine instances of pleural effusion, five instances of 50/1051
TABLE. Clinical characteristics of children with pulmonary contusion Parameter
No. of Patients
Traumatic Event Motor vehicle-pedestrian collision Crush injury Fall Presenting Clinical Features Respiratory rate (breaths/min) < 20 20 - 30 3O - 4O > 40 Abnormal breath sounds Cyanosis Hemoptysis Extrathoracic Lesions Neurologic Skull fracture Intracranial lesion* Abdominal* Hepatic lesion Renal lesion Splenic lesion Orthopedic Long-bone fracture Pelvic fracture Thoracic Wall Lesions Dermal contusion-abrasion Rib fracture Clavicle fracture Scapula fracture Intrathoracic Lesions Pleural effusion Pneumothorax Hemothorax Flail chest Great-vessel injury *Lesion present on computed tomography scan. tFour cases with unspecified pleural fluid collection on radiograph.
pneumothorax, and two instances of hemothorax, lesions were not present on admission radiograph. Of 15 patients with fractures of the bony thorax, 14 experienced at least one of these a s s o c i a t e d i n t r a t h o r a c i c lesions. DISCUSSION Trauma is the most common cause of death in children more than 1 year old. Up to 30% of traumatized children sustain injuries to the thorax,S, 6 with an associated m o r t a l i t y rate ranging from 7% to 14% in older children and up to 25% in children less than 5 years old. 4,6 Pulmonary Annals of Emergency Medicine
30 3 2
3 16 10 6 16 2 0
12 5 10 5 2 23 3 16 10 4 1 14t 10 2 0 0
contusion, defined as injury to lung parenchyma with edema and interstitial hemorrhage, is frequently associated w i t h severe b l u n t t h o r a c i c trauma. It is a disorder capable of progressing to respiratory insufficiency due to ventilation-perfusion abnormalities resulting from disruption of the alveolar-capillary interface.7,8 In contrast with a previous survey of pediatric thoracic trauma, 9 we observed that the majority of children with pulmonary contusion secondary to blunt thoracic trauma were more than 5 years old. In accordance with previous reports,>4, 9ql 90% of chil18:10 October 1989
dren i n our series were v i c t i m s of motor v e h i c l e - r e l a t e d accidents. Also in accord w i t h previous findings, T M we noted that the majority of these c h i l d r e n (more t h a n 80%) experienced m u l t i p l e trauma and had an a c c o m p a n y i n g i n j u r y to at least one other major organ system, underscoring the significant-impact nature of the traumatic event. The a b s e n c e of signs of e x t e r n a l chest w a l l i n j u r y a n d r e s p i r a t o r y compromise on i n i t i a l e x a m i n a t i o n was c o m m o n i n c h i l d r e n w i t h pulm o n a r y c o n t u s i o n . As i n d i v i d u a l variables, t h e a n t i c i p a t e d c l i n i c a l f i n d i n g s of t a c h y p n e a , a b n o r m a l breath sounds, external thoracic wall contusion, and fracture of the b o n y thorax w e r e each a b s e n t i n m o r e than 50% of p a t i e n t s w i t h p u l m o nary contusion. The absence of these abnormalities on p r e s e n t a t i o n does not preclude u n d e r l y i n g injury to the lung. The radiographic features of children with p u l m o n a r y c o n t u s i o n were varied and dynamic. Of note was that in almost every instance, the full radiographic e x t e n t of c o n t u s i o n was present at the t i m e of a d m i s s i o n . This, c o m b i n e d with the finding that no patient experienced clinical deterioration i n respiratory status after initial p r e s e n t a t i o n , w o u l d seem to conflict w i t h the claim that pulmonary c o n t u s i o n progresses c l i n i c a l l y to its m a x i m u m extent by the second or t h i r d day a f t e r t h e t r a u m a t i c event. 12 The majority of children w i t h pulmonary c o n t u s i o n did not experience fracture of the bony thorax. In contrast w i t h the findings of a previous series of adults w i t h b l u n t thoracic trauma in which more than 70% experienced fractures of the bony thorax, u we found only 40% of children with this type of associated injury; specifically, o n l y 28% e x p e r i e n c e d rib fracture. As opposed to reports that d o c u m e n t e d flail chest in nearly 0ne-fourth of adults with b l u n t tho-
18:10 October 1989
racic trauma, m, n no instance of this c o m p l i c a t i o n occurred in any child in our series. Both the lower rate of rib fracture and absence of flail chest in children m a y be a reflection of the greater elasticity of the pediatric cartilaginous and bony skeleton. Intrathoracic lesions associated w i t h p u l m o n a r y c o n t u s i o n occurred in a p p r o x i m a t e l y 60% of p e d i a t r i c cases. P n e u m o t h o r a x , u s u a l l y cited as the most c o m m o n complication of pediatric thoracic injury, 13 occurred with less frequency than did pleural effusion-hemothorax. In accord with p r e v i o u s reports,9, lo a l m o s t all instances of p u l m o n a r y c o n t u s i o n w i t h rib f r a c t u r e were a s s o c i a t e d w i t h pneumothorax and/or pleural e f f u s i o n - h e m o t h o r a x . The radiographic appearance of these associated lesions was c o m m o n l y delayed up to 48 hours after the appearance of p u l m o n a r y c o n t u s i o n . T h e presence of rib fracture in a child with b l u n t thoracic trauma should heighten awareness for the possible developm e n t of o n e of t h e s e p o t e n t i a l l y treatable underlying complications and warrant serial radiographic evaluation. The o u t c o m e of these children was u n i f o r m l y good. N o c h i l d experienced respiratory insufficiency, w h i c h c o n t r a s t s w i t h p r e v i o u s reportslO, H, 14 i n w h i c h up to 40% of adult p a t i e n t s w i t h p u l m o n a r y cont u s i o n required assisted v e n t i l a t i o n . Although only about one-half of all p a t i e n t s received arterial blood gas analysis, the m a j o r i t y exhibited hyp o x e m i a - y e t m o s t c h i l d r e n required only supportive care and experienced an u n c o m p l i c a t e d clinical course w i t h regard to respiratory status. CONCLUSION P u l m o n a r y c o n t u s i o n i n children is u s u a l l y a s s o c i a t e d w i t h signific a n t - i m p a c t t r a u m a and has a good prognosis. Despite a paucity of abnorm a l c l i n i c a l f i n d i n g s , all c h i l d r e n
Annals of Emergency Medicine
who sustain injuries from highi m p a c t or c r u s h i n g - t y p e t r a u m a should receive radiographic evaluation of the chest to assess for possible i n t r a t h o r a c i c injury. W h e n pulm o n a r y c o n t u s i o n is associated with fracture of the bony thorax, serial radiographic e v a l u a t i o n of the chest should be performed during the subs e q u e n t 48 hours of h o s p i t a l i z a t i o n to m o n i t o r for delayed onset of complications.
REFERENCES
1. Bellinger SB: Penetrating chest injuries in children. Ann Thorac Surg 1972;14:635-644. 2. DougallAM, Paul ME, FinleyRJ, et al: Chest trauma - Current morbidity and mortality. I Trauma 1977;17:547-553. 3. LevyJL: Managementof crushing injuries in children. South Med I 1972;65:1040-1044. 4. Smyth BT: Chest trauma in children. J Pediatr Surg 1979;14:41-46. 5. Vclcek FT, Weiss A, DiMaio D, et al: Traumatic death in urban children. J Pediatr Surg 1977;12:375-379. 6. SinclairMC, Moore T: Major surgery for abdominal and thoracic trauma in childhood and adolescence. J Pediatr Surg 1974;9:155-158. 7. Ratliff JL, Fletcher JR, KoprivaCJ, et al: Pulmonary contusion: A continuing management problem. J Thorac Cardiovasc Surg 1971;62: 638-644. 8. Hankins JR, Attar S, Turney SZ, et al: Differential diagnosis of pulmonary parenchymal changes in thoracic trauma. A m Surg 1973; 39:309-318. 9. MellerJL, Little AG, Shermeta DW: Thoracic trauma in children. Pediatrics 1984;74:813-819. 10. Johnson JA, Cogbill TH, Winga ER: Determinants of outcome after pulmonarycontusion. J Trauma 1986;26:695-697. 11. Schorr RM, Crittenden M, Indeck M, et al: Blunt thoracic trauma: Analysisof 515 patients. Ann Surg 1987;206:200-205. 12. Williams JR, Bonte FJ: Pulmonary changes in non-penetratingthoracic trauma. Texas State Med J 1963;59:27-30. 13. Eichelberger MR, Randolph JG: Thoracic trauma in children. Surg Clin North Am 1981; 61:1181-1198. 14. Clark GC, Schecter WP, Trunkey DD: Variables affecting outcome in blunt chest trauma: Flail chest vs pulmonary contusion. J Trauma 1988;28:298-304.
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