Original Article

Challenges in Management of Pediatric Life‑threatening Neck and

Chest Trauma
Shilpa Sharma, Biplab Mishra1, Amit Gupta1, Kapil Dev Soni2, Richa Aggarwal2, Subodh Kumar1

Department of Pediatric Introduction: Neck and thoracic trauma in children pose unforeseen challenges
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Abstract
Surgery, All India Institute
of Medical Sciences,
requiring variable management strategies. Here, we describe some unusual cases.
Departments of 1Trauma Patients and Methods: Pediatric cases of unusual neck and thoracic trauma
Surgery and 2Intensive and prospectively managed from April 2012 to March 2014 at a Level 1 trauma center
Critical Care, JPN Trauma were studied for management strategies, outcome, and follow‑up.
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Centre, All India Institute Results: Six children with a median age of 5.5 (range 2–10) years were
of Medical Sciences, managed. Mechanism of injury was road traffic accident, fall from height and
New Delhi, India
other accidental injury in 2, 3 and 1 patient respectively. The presentation was
respiratory distress and quadriplegia, exposed heart, penetrating injury in neck,
dysphagia and dyspnea, and swelling over the chest wall in 1, 1, 1, 2 and 1 cases
respectively. Injuries included lung laceration, open chest wall, vascular injury of
the neck, tracheoesophageal fistula (2), and chest wall posttraumatic pyomyositis.
One patient had a flare of miliary tuberculosis. Immediate management included
chest wall repair; neck exploration and repair, esophagostomy, gastroesophageal
stapling, and feeding jejunostomy (followed by gastric pull‑up 8 months later).
Chest tube insertion and total parenteral nutrition was required in one each. 2 and
4 patients required tracheostomy and mechanical ventilation. The patient with
gastric pull‑up developed a stricture of the esophagogastric anastomosis that was
revised at 26‑month follow‑up. At follow‑up of 40–61 months, five patients are
well. One patient with penetrating neck injury suffered from blindness due to
massive hemorrhage from the vascular injury in the neck and brain ischemia with
only peripheral vision recovery.
Conclusion: Successful management of neck and chest wall trauma requires
timely appropriate decisions with a team effort.

Received: June, 2017.

Keywords: Posttraumatic pyomyositis, thoracic injury, traumatic
Accepted: October, 2017. tracheoesophageal fistula

Introduction in children where greater forces are applied per unit

of body surface area due to the traumatic impact, as
T horacic trauma accounts for only 5%–12% of
admissions to a trauma center. However, it is the
second most common cause of mortality due to trauma,
compared to adults. Half of the children with thoracic
trauma have a multisystem involvement. The initial
especially in children, after head injury. Children with management of pediatric trauma is based on Advanced
thoracic trauma may present with diagnostic challenges Trauma Life Support (ATLS) principles. However, the
due to their unique thoracic anatomical and physiological
features.[1] The presence of a chest injury increases an Address for correspondence: Dr. Subodh Kumar,
Department of Trauma Surgery, JPN Trauma Centre, All
injured child’s mortality by 20‑fold.[2] India Institute of Medical Sciences, New Delhi, India.
E‑mail: [email protected]
The closer proximity of the vital organs in the thorax
makes it prone to life‑threatening injuries, especially This is an open access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
Access this article online and build upon the work non-commercially, as long as the author is credited and the new
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Website: www.jiaps.com For reprints contact: [email protected]

How to cite this article: Sharma S, Mishra B, Gupta A, Soni KD,

Aggarwal R, Kumar S. Challenges in management of pediatric
DOI: 10.4103/jiaps.JIAPS_49_17 life-threatening neck and chest trauma. J Indian Assoc Pediatr Surg
2018;23:10-5.

10
10 © 2017 Journal of Indian Association of Pediatric Surgeons | Published by Wolters Kluwer ‑ Medknow
 Sharma, et al.: Pediatric thoracic trauma

further management of life‑threatening pediatric neck The presentation is depicted in Table 1. The mechanism
and thoracic trauma requires a multi‑team approach of injury was road traffic accident; fall from height
and has many lessons to learn for the pediatric surgeon. during playing, and accidental injury by metal splinter
Although each case requires individualized care, we misfired by a goldsmith while sleeping in 2, 3 and
have compiled our experience in managing some unusual 1 patients respectively. The type of injuries, management
cases involving neck and thorax to form a compendium, strategies adopted, and complications encountered are
including discussion of relevant literature.
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shown in Table 1. Associated injuries included spinal

injury in one, vertebral injury in one, and depressed
Patients and Methods skull fracture with fracture femur in one. Three cases
Pediatric cases, of age less than or equal to 12 years, of had presented with a delayed presentation following
unusual neck and thoracic trauma that were prospectively
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trauma; respiratory distress and incomplete quadriplegia

managed from April 2012 till March 2014 at a Level 2 weeks after trauma; esophageal perforation and
1 trauma center were studied for the management small tracheoesophageal fistula referred with a chest
strategies and outcome.
tube 10 days after injury for further management,
Results and posttraumatic pyomyositis following chest wall
hematoma 3 days after road traffic accident as he fell
Six cases of unusual neck and chest wall trauma
from the hands of his mother.
were managed during this period. All cases were
managed as per the ATLS guidelines. Median age was The other patient of tracheoesophageal injury was
5.5 years (range 2–10 years). All six patients were boys. stabilized and discharged after 20 days. His cervical

Table 1: Clinical features, management and associated complications of the Cases

Case Age in Presentation Type of Injuries Management Length of hospital Complications
years stay in days
1. 10 Respiratory Lung laceration Artificial mechanical ventilation 36 Incomplete
Distress and with miliary Chest tube insertion Quadriplegia
Quadriplegia tuberculosis with Ionotropes Septic Shock
spinal injury Tracheostomy Pericardial Effusion
Antitubercular treatment
2. 5 Exposed Open chest wall Immediate chest wall repair 5 None
beating heart wound involving Elective Artificial mechanical ventilation
sternum with Chest tube insertion
depressed skull
fracture of right
parietal bone with
fracture right femur
3. 3 Penetrating Vascular injury of Immediate neck exploration and repair 38 Haemorrhagic shock
Injury in neck Artificial mechanical ventilation Ischemic hepatitis
neck Massive Blood Transfusion Coagulopathy,
Ionotropes Multiple organ
Ventriculoperitoneal shunt dysfunction syndrome,
Tracheostomy Hydrocephalus,
Posterior cerebral
venous ischemic infarct
4. 6 Dysphagia Tracheoesophageal Chest tube insertion. Managed conservatively 35 Malnutrition
and Dyspnea Fistula Total parenteral nutrition
5. 7 Dysphagia Tracheoesophageal Diversion: Esophagostomy , 20 (later 21 ; Complete Stenosis
and Dyspnea Fistula with Gastroesophageal stapling and feeding 15 days for further of Cervical
vertebral injuriesjejunostomy, Artificial mechanical ventilation surgeries) Esophagostomy,
followed by bronchoscopy and retrosternal delayed stricture of
gastric pullup 8 months later, revision of the esophago‑gastric
esophagogastric anastomosis and excision of anastomosis
redundant cervical esophagus.
6. 2 Swelling Chest wall Incision and debridement, Inotropes, 21 Sepsis
over chest haematoma leading Artificial mechanical ventilation Disseminated
wall to pyomyositis Vacuum assisted closure dressing, ultrasound pyoderma.
guided aspiration of abscesses.

Journal of Indian Association of Pediatric Surgeons / Volume 23 / Issue 1 / January-March 2018 11

 Sharma, et al.: Pediatric thoracic trauma

esophagostomy closed completely in 2‑month time, but patients [Table 1]. Operative interventions (1–3) were
the patient learnt to spit out his secretions by mouth. At required in five patients. The patient with vascular
8‑months follow‑up, the computed tomography (CT) scan injury of the neck developed hydrocephalus, for which a
showed a tracheoesophageal defect that was confirmed ventriculoperitoneal shunt was put. He later had posterior
on bronchoscopy as a defect of 4 cm [Figure 1a]. He cerebral venous ischemic infarct as a later complication
developed bradycardia on the operating table when due to massive hemorrhage from the vascular injury in
posted for a gastric pull‑up due to which the surgery the neck and brain ischemia, leading to blindness. He
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was postponed. On further investigation, no cause could had a peripheral vision recovery at 3‑month follow‑up.
be found, and it was hypothesized that the distended The other five patients are well. Hence, at a follow‑up
cervical esophageal pouch had produced bradycardia of 40–61 months, all 6 patients are alive.
due to compression on the vagus nerve. The distended
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cervical esophagus measured 5 cm and had a kink on Discussion

preoperative ultrasonography. A redo gastroesophageal Thoracic injuries in children are not so common and
junction dissociation, and retrosternal gastric pull‑up with only about 10%–15% require operative intervention.[3]
pyloric canal dilatation was done with esophagogastric Fortunately, the majority of thoracic trauma in children
anastomosis in the neck [Figure 1b with insert]. The requiring treatment is due to blunt trauma.[4] A high
anastomosis healed well in the immediate postoperative index of suspicion is needed to suspect a dangerous
period without any leak or stenosis. However, during mechanism of injury. The compliant pediatric thorax
follow‑up, the patient presented with dysphagia due to and pliable cartilage and bony thoracic cage enable the
stricture of the esophagogastric anastomosis that was chest to absorb a large amount of kinetic energy from
revised at 26‑month follow‑up. The redundant cervical the impact, which is subsequently transferred to the
esophagus was also excised. intrathoracic structures. Thus, often the child may have
The posttraumatic hospital stay varied from 5 to major intrathoracic injury with minimal or no injury to
38 days [Table 1]. The patient with an open chest wall the thoracic bony cage comprising of the ribs, sternum,
was repaired immediately, the subcutaneous tissue and and scapula. Thus, pulmonary contusion has been
skin were closed as a delayed primary closure [Figure 2]. reported as the most common thoracic injury that may
He could be discharged in 5 days. Four patients required comprise up to 50% of the cases.[3,5]
therapeutic artificial mechanical ventilation while one Penetrating trauma constituting 15% of chest injuries in
was electively ventilated postoperatively. Two patients children are seen most often in war‑hit countries, caused
on prolonged artificial ventilation and inotropes required by gunshots, knife wounds, and injury from other
tracheostomy for better tracheal toileting. Both the sharp objects. In cases of penetrating pediatric neck
patients were successfully weaned off the ventilator, and chest trauma, there is great urgency as a relative
kept on T‑piece for few days and decannulated before small blood volume loss can lead to hypovolemia and
discharge. Early complications were seen in five shock, due to the low volume of blood in children.
The case of penetration neck injury that presented to
us had already bled a lot at the site of trauma and at
another peripheral hospital before he was referred to
us. The metallic splinter had traversed the posterior

b
a c
Figure 1: (a) A computerized tomography scan of the chest showing a
wide traumatic tracheoesophageal defect. (b) Stomach mobilized and Figure 2: (a) Open chest wall showing a beating heart. (b) Computed
pulled up to replace the esophagus and an esophagogastric anastomosis tomography scan done during the postoperative period. (c) Subcutaneous
done in the neck (insert) tissue and skin were closed as a delayed primary closure

12 Journal of Indian Association of Pediatric Surgeons / Volume 23 / Issue 1 / January-March 2018

 Sharma, et al.: Pediatric thoracic trauma

wall of the internal jugular vein and during surgery regularly monitored with echocardiography to assess the
had travelled to the brachiocephalic vein due to the heart function. He did not respond to prolonged higher
negative venous pressure. It was very difficult to retrieve antibiotics but responded on initiation of antitubercular
the metallic piece from the pool of blood on the table. treatment.
The child had required massive blood transfusion, and Less than 15% of cases of thoracic trauma in children
the subsequent complications were hemorrhagic shock, require thoracotomy. None of the cases described here
and coagulopathy. While the cause of mortality in
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needed a formal thoracotomy, though multiple surgeries

penetrating injuries is the penetrating injury itself, the were required including tracheostomy and neck and
cause of mortality in half of the blunt trauma cases is abdomen exploration for gastric pull‑up.
neurological injury.[3] The associated head injury is also
an important cause of mortality. Sequelae of pulmonary contusion in children include
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pneumonitis and posttraumatic pseudocysts, as the

Resuscitation of the child with thoracic trauma begins more elastic and pliable chest wall of children permits
with a survey for immediate life‑threatening injury. the transmission of kinetic energy more efficiently to the
Major thoracic injuries are known as the deadly dozen.[6] underlying lung parenchyma.[10] The concussive forces
The immediate life‑threatening thoracic injuries or lethal of a high‑velocity impact with low displacement of the
six including airway obstruction, open pneumothorax, chest wall result in a peripheral pseudocyst, whereas the
tension pneumothorax, massive hemothorax, flail chest, compressive forces of a low‑velocity impact with high
and cardiac tamponade should be identified in the displacement of the chest wall resulting in a central
primary survey. The potential life‑threatening thoracic pseudocyst.[11] These typically resolve with antibiotics
injuries or hidden six including pulmonary contusion, and time.
widened mediastinum/aortic transection, ruptured Children presenting after blunt chest trauma may have
tracheobronchial tree, ruptured diaphragm, esophageal complete disruption of the airway with little external
perforation, and myocardial contusion should not be sign of injury. The suspicion should be high in the
missed during the secondary survey. Out of the six cases presence of pneumothorax and pneumomediastinum
described here, two had life‑threatening emergencies, that are refractory to adequate pleural drainage.[12]
whereas three had potential life‑threatening injuries. Bronchoscopy is helpful to identify the location of
The case of pyomyositis had also become a potential injury. Guided flexible bronchoscopy with intubation
life‑threatening injury due to the setting in of sepsis. distal to the injury was used to intubate the child with
A thorough and focused evaluation for thoracic injuries tracheoesophageal fistula described here to give general
is required to discover the extent and severity of these anesthesia. Advance preparation for a cardiopulmonary
injuries.[7] Failure to promptly diagnose immediate bypass along with thoracotomy should be done in case
life‑threatening thoracic injuries and treat these injuries primary repair is contemplated.
results in exponentially increased morbidity and In many instances with trivial tracheobronchial trauma,
mortality that may approach 50%.[2,7] Holmes et al. the diagnosis may be missed. In a 10‑year review of
reported the predictors of thoracic injury in children delayed diagnoses of traumatic tracheobronchial injuries,
sustaining blunt torso trauma as low systolic blood the median time from initial presentation to diagnosis
pressure, elevated respiratory rate, abnormal results was reported as 6 months.[13] Dyspnea (56%) and
on thoracic examination, abnormal chest auscultation pneumonia (39%) were the most common complaints.[13]
findings, femur fracture, and Glasgow Coma Scale score Bronchial sleeve resections or end‑to‑end anastomosis
of <15.[8] can be performed safely in most situations.[13] There was
A chest X-ray is sufficient in most cases. A CT no difference in complications was observed between
scan is advised only after stabilization to decide parenchymal sparing procedures and resections.[13]
the further course of management. Holscher et al. Early diagnosis of esophageal injury significantly
concluded after comparing chest CT scan imaging reduces the complications and mortality. Perforations
and chest radiographs that CT scan did not add to the of the cervical esophagus can present with neck pain,
management of the trauma and increased the risk from cervical dysphagia, dysphonia, or regurgitation of blood.
radiation.[9] In the case with lung laceration with spinal Intrathoracic perforations can rapidly contaminate
injury, a diagnosis of miliary tuberculosis could be made the mediastinum, leading to chest pain, tachycardia,
due to the presence of mediastinal lymphadenopathy tachypnea, fever, and leukocytosis. Children are often
and pericardial effusion on CT scan and cervical spine not able to communicate the symptoms, and sick look
contusion on magnetic resonance imaging. He was of the child with painful respiration should raise the

Journal of Indian Association of Pediatric Surgeons / Volume 23 / Issue 1 / January-March 2018 13

 Sharma, et al.: Pediatric thoracic trauma

suspicion for further evaluation. A chest X-ray may with abscess formation.[16] Predisposing factors for
reveal mediastinal widening with or without an air‑fluid pyomyositis include immunodeficiency, trauma, injection
level, subcutaneous emphysema, and a pleural fluid drug use, concurrent infection, and malnutrition.
collection. A lateral skiagram of the neck may reveal air
Mechanical ventilation in children after chest trauma
in the prevertebral fascial planes in cervical esophageal
requires a balance between sufficient ventilation and
perforation. On suspicion of an esophageal perforation,
the avoidance of barotrauma to the inflamed lung
a water‑soluble contrast study should be performed.
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A well‑contained leak can be managed with careful parenchyma.[17] An elective tracheostomy was done
observation, successful negotiation of a nasogastric in two patients to support the lung toilet while on
tube if feasible under guidance, keeping the patient ventilator. Tracheostomy in a child is a concern and
nothing by mouth, broad‑spectrum antibiotics, and total requires weighing the risks versus the merits.[18,19] With
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parenteral nutrition. A chest tube may be inserted if sophisticated, patient‑friendly tracheostomy tubes, the
there is thoracic collection. This may be progressed to use may be extended to selected children in whom
drip in feeds after 2 weeks. The contrast study may be prolonged ventilatory support more than 2 weeks is
repeated after 3 weeks to check for the healing. anticipated.

If the leak is not contained, the site of perforation It has been reported that regardless of the mechanism
dictates further management. If the patient is stable of thoracic trauma, 15%–25% of children with thoracic
and the defect is less than 3 cm, the esophagus may injury do not survive, depending on the severity of the
be explored. The upper‑ and mid‑esophagus are best drainage of patients to the level of hospital.[20,21] The
approached through the right side of the chest, whereas mortality is around 5% for isolated thoracic trauma and
the lower third of the esophagus and the esophagogastric increases with concomitant injuries, up to 20%–25%
junction are best approached through the left side of with abdominal, 30%–35% with head injuries, and 40%
the chest. Some pleural or intercostal muscle covering with combined head, thorax, and abdominal injury.[20,21]
should accompany debridement and primary repair. Wide The mortality in thoracic injuries depends on the organ
drainage of both the mediastinum and pleural space is involved. Peclet et al. reported that injuries to the heart
mandatory. Video‑assisted thoracoscopic drainage for or great vessels had the highest mortality rate (75%),
esophageal perforation with mediastinitis in children has followed by hemothorax (53%), lung laceration (43%),
been shown to be feasible and effective.[14] and rib fracture (42%).[20]
In unstable patients, in the presence of inflammation
and infection, extensive injury, large tracheoesophageal Conclusion
communication more than 3 cm and in cases with About 75% of pediatric chest injuries worldwide are
life‑threatening tracheoesophageal injury as in one case caused by motor vehicle accidents, with the remainder
described here, a diversion procedure in the form of attributable to motorcycle‑related trauma, falls, and
cervical esophagostomy in emergency is lifesaving. This bicycle accidents. These are thus preventable injuries.
may be followed by eventual esophageal replacement. Awareness on preventive aspects would help to prevent
a potential cause of morbidity and mortality.
The case described here has a residual piece of
esophagus attached to the posterior wall of the trachea There can be a varied presentation of life‑threatening
and is in regular follow‑up to see for any complication. neck and chest wall trauma in children. Successful
The gastroesophageal junction had opened up as management requires repeated evaluation and timely
demonstrated during the surgery for gastric pull‑up. The appropriate decisions. The surgical options should
gastroesophageal junction has now been disconnected be considered appropriately without haste. The
completely as high as possible through the abdomen. life‑threatening cases described here were adequately
He et al. described successful surgical management managed and survived. Even cases with a delayed
of 3 cases including a 6‑year‑old child with huge diagnosis and complications can be managed successfully
posttraumatic tracheoesophageal fistula (>5 cm in with a goal‑directed multidisciplinary team effort. All
length) with esophagus segment in situ as replacement pediatric surgeons should adopt the ATLS principles
of the posterior membranous wall of the trachea.[15] religiously in the initial assessment and management of
traumatic cases to prevent immediate mortality and limit
One of the cases had a posttraumatic pyomyositis
morbidity.
that presented as a soft‑tissue swelling over the chest
wall. Pyomyositis is a purulent infection of skeletal Financial support and sponsorship
muscle that arises from hematogenous spread, usually Nil.

14 Journal of Indian Association of Pediatric Surgeons / Volume 23 / Issue 1 / January-March 2018

 Sharma, et al.: Pediatric thoracic trauma

Conflicts of interest 11. Lau VK, Viano DC. Influence of impact velocity and chest
compression on experimental pulmonary injury severity in
There are no conflicts of interest. rabbits. J Trauma 1981;21:1022‑8.
12. Grant WJ, Meyers RL, Jaffe RL, Johnson DG. Tracheobronchial
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Journal of Indian Association of Pediatric Surgeons / Volume 23 / Issue 1 / January-March 2018 15