SINGING THUNDER WITH BROKEN PIPES: A CHALLENGE IN

STABILIZING PEDIATRIC BLUNT COMPLEX CHEST TRAUMA IN

DISTRICT HOPITAL.
SFA B. JAWITH ALIAR*, AA E Arim Sasi*, MN AB RAZAK*.
*Emergency & Trauma Department, Hospital Lahad Datu

We describes an initial management and stabilization of one paediatric patient with blunt complex chest trauma comprise of tracheal injury, oesophageal injury,
pneumomediastinum, bilateral pneumothorax and extensive subcutaneous emphysema in a non paediatric trauma centre of Lahad Datu District Hospital,
Sabah.

[A] The arrow shows 2X2 cm bruises at anterior chest region. [B] The untrained eyes may fail to appreciate a pneumomediastinum and large pneumothorax of the left chest due to
massive subcutaneous emphysema that overshadow it. [C] Massive left pneumothorax with left lung atelectasis. Noted also, present of subcutaneous emphysema, air surrounding the
trachea lining as well as pneumomediastinum. [D] peri oesophageal fluid accumulation. [E] Patient was intubated, sedated, put on mechanical ventilators and bilateral chest tube was
inserted.

This unfortunate 8 years old girl was playing outside of her house with her
cousin when lightning stroked the concrete wall, causing a break to it and hit
her chest. She was standing at approximately 1 meter distance from the wall.
She was brought to our centre 3 hours post event due to logistic problem.
Upon arrival, she was fully conscious and alert but with minor
haemodynamically impairment. Her respiratory rate was 21 with oxygen
saturation of 96% under room air, pulse rate 139 beat per minute, blood
pressure 139/80 mmHg and pain score of 4/10. During initial assessment, she
becoming more tachypnoeic despite of oxygen saturation of 98% and she was
supplemented with nasal prong 2L/min. Trachea was centraly located. There
was a bruise over her anterior chest measuring about 2X2cm and extensive
subcutaneous emphysema over the neck, chest and bilateral shoulder region.
Air entry minimally reduced at bilateral lower chest region. Examination of
other system were unremarkable.
Initial Chest X Ray showed pneumomediastinum and suspicious of left
pneumothorax that was overshadowed by massive subcutaneous
emphysema. She was electively intubated for airway protection and send for
CT Thorax and Brain. CT Brain was normal. CT Thorax confirmed the presence
of left pneumothorax with almost collapsed left lung as well as small right
pneumothorax. There was segmental collapse of the posterior and medial
segment of right lower lobe as well. The tracheal wall was disrupted at the
postero-inferior aspect of carina measuring 1.1 cm with jutting of
endotracheal tip just below the carina defect. There was extensive
pneumomediastinum surrounding the heart and great vessel extending to the
generalized subcutaneous emphysema at the neck, thorax and visualized
abdomen and upper limbs. Apart from that, there was a small defect at the
right postero-lateral oesophageal wall measuring 2mm at T8 and small
accumulation of fluid at the right posterior mediastinum.
Bilateral chest tube was inserted and she was stabilized overnight in surgical
ward before transferred to paediatric trauma centre via ground ambulance
which was located 395km away from our centre in the capital city of Sabah
Thoracic trauma has caused significant morbidity and mortality among
paediatric patients, even though it is rare among children.[1] These injury can
be presented as rib fractures, lung injury, haemothorax, pneumothorax,
mediastinal injuries, and others; in combination or isolation.[1]
Among those injuries, pneumothorax may occur in isolation or in combination
with other injuries. Two third of pneumothorax cases has association with
other intrathoracic or extra thoracic injuries [1]. All traumatic pneumothorax
should be assumed to have risk to cause cardiopulmonary compromise,
therefore screening chest radiography and prompt drainage should be
performed[1].
As in this patient, the pneumothorax is also associated with tracheo-
oesophageal injury. Tracheal bronchial injury is rarely occurs in children and it
is more common in penetration injury, although it may occur in blunt
trauma[1]. Oesophageal traumatic injury is extremely rare especially in blunt
thoracic injury.[2] This case is unique as it composed of multiple injuries
associated with blunt trauma, hence we define it as blunt complex chest
trauma.
Managing pediatric blunt complex chest trauma is an extremely difficult task if
you are working in a non pediatric trauma centre with lack of expertise and
facilities to deal with this life threatening event.
A trauma education should be conducted from time to time in district hospital
and junior doctor should be trained in making a fast and correct diagnosis
based on clinical finding and imaging. They should be able to perform the
required emergency procedures in order to stabilize the patient and
optimizing their condition prior to a long journey to the specialized pediatric
trauma center.
Apart from that, challenges may arise from patients late presentation, lack of
experience from treating physician and ineffective communication and
coordination for transferring of critically ill pediatric trauma patient.

[1] Paediatric thoracic trauma, David Bliss; Mark Silen, 2002. Pediatric blunt complex chest trauma should be suspected in pediatric patient
[2] Pathogenesis and outcomes of traumatic injuries of the esophagus, M. presented with blunt trauma to the chest. Aggressive with timely manner
Makhani, D. MIdani, A. Goldberg, F.K. Friedenberg, 2013. management as well as good team work among healthcare provider can
improve the outcome of the patient.