The priorities for treatment are, in order, the airway, breathing, and circulation. Whether the child is agonal, unstable, or stable determines how one meets these priorities.
The most reliable way to secure the airway is endotracheal intubation employing a rapid sequence intubation technique. Emergent intubation may be required in the trauma bay for several reasons. First, a decreased level of consciousness, typically a Glasgow Coma Scale (GCS) score of less than 8; second, impaired ventilation and oxygenation related to a chest injury such as a massive hemothorax, flail chest, or severe pulmonary contusions; and finally, patient agitation that interferes with diagnostic studies and treatment.
Pulse oximetry to continuously monitor oxygenation and inline capnography to monitor CO2 levels are important adjuncts in the management of the airway in the trauma bay. Inline capnography to detect excessive or inadequate ventilation is especially useful for the child with an associated head injury in whom improper ventilation can further reduce already compromised cerebral perfusion.
Emergency department (ED) thoracotomy should be performed solely for patients having suffered a penetrating injury with signs of life either at the scene or on arrival. A meta-analysis of 2399 patients in 22 different series found a 35% survival rate following ED thoracotomy in victims of penetrating trauma with signs of life on arrival, and a 14% survival rate for those with signs of life at the scene that were lost prior to arrival at the ED. Victims of penetrating trauma with no signs of life at the scene and all victims of blunt trauma had a poor outcome after ED thoracotomy, with a collected survival rate of less than 1% (Table 80-1).
Table 80-1Meta-Analysis of Collected Series of Patients Undergoing ED Thoracotomy |Favorite Table|Download (.pdf) Table 80-1 Meta-Analysis of Collected Series of Patients Undergoing ED Thoracotomy
|Injury Type ||No Signs of Life at the Scene ||Signs of Life at the Scene, not on Arrival ||Signs of Life on Arrival to ED |
|Penetrating ||0/635 ||111/770 (35%) ||126/365 (14%) |
|Blunt ||0/154 ||1/187 (<1%) ||1/228 (<1%) |
As the airway and breathing are secured, the left chest is incised from the midclavicular line to the posterior axillary line through the inframammary crease. The incision is carried sharply through the fifth interspace and the pleura is incised with scissors. A rib spreader is placed, the inferior pulmonary ligament is divided, and the left lung is retracted superiorly (Fig. 80-2). Once inside the pleural cavity, the pericardium is inspected for bulging and/or discoloration, which may indicate pericardial tamponade. The pericardium is incised vertically with scissors anterior to, and with care taken to protect, the phrenic nerve. This incision must be large enough to allow manual internal cardiac compression (Fig. 80-3). Extension of the left anterolateral thoracotomy through the sternum and into the right chest will allow full exposure of the heart for penetrating cardiac injuries, or should significant right-sided hemothorax be noted after the left chest has been opened. Depending upon the bony maturation of the child, heavy scissors or a saw may be used to traverse the sternum (Fig. 80-4). To diminish ongoing hemorrhage during resuscitation, the thoracic aorta may be clamped just above the diaphragm. The parietal pleura overlying the aorta just above the diaphragm should be incised vertically and the nearby mesenchymal tissue dissected bluntly to separate the esophagus. The aorta is then clamped with a large vascular clamp. Care should be taken, if possible, to locate and avoid the anterior spinal artery to decrease the chance of paraplegia (Fig. 80-5).
Location of incision for left resuscitative thoracotomy.
Evacuation of pericardial tamponade.
Extension of the left anterolateral thoracotomy to the right, the “clam shell” thoracotomy.
If the child has a parasternal penetrating wound and is hemodynamically stable, echocardiography should be performed to detect pericardial fluid. Transthoracic and transesophageal approaches are the ones most commonly employed in the trauma setting. If bandages, chest tubes, or massive subcutaneous emphysema preclude the more expeditious transthoracic approach, the transesophageal echocardiography should be considered to detect the presence of pericardial fluid and to identify aortic injury. Parenthetically, pericardial fluid may also be identified in the course of a FAST examination of the injured child. Children and adolescents have extraordinary compensatory means and can harbor cardiac tamponade and appear well for some time, only to decompensate rapidly and die unless appropriate interventions take place. Clinical signs consisting of hypotension, muffled heart sounds, and distended neck veins are insensitive and are infrequently seen in children with pericardial tamponade.
The stable patient with evidence of pericardial fluid should undergo an expeditious subxiphoid pericardotomy in the controlled setting of the operating room. This approach is preferred over pericardiocentesis in the trauma bay. However, pericardiocentesis can be easily performed in the trauma bay and can serve as a bridge therapy while preparing to do the subxiphoid window in the operating room.
Operating instruments should be available for potential sternotomy, as should blood products, in case significant hemorrhage is encountered. A vertical midline upper-abdominal incision is made and is carried down through the midline fascia and to the left of the xiphoid, which is either retracted to the right or resected. The lowest anterior aspect of the pericardium is grasped and a small, controlled, pericardiotomy is made (Fig. 80-6). If extensive hemorrhage is encountered, the pericardotomy is held closed while the incision is carried up through the sternum. If controlled hemorrhage is encountered, then the pericardial fluid is evacuated and a drain is placed.
Subxiphoid approach for pericardial fluid or for placement of a pericardial window.