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.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 04/12/2024

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

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,
especially in children, after head injury. Children with
thoracic trauma may present with diagnostic challenges
due to their unique thoracic anatomical and physiological
features.[1] The presence of a chest injury increases an
injured child’s mortality by 20‑fold.[2]
The closer proximity of the vital organs in the thorax
makes it prone to life‑threatening injuries, especially
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of body surface area due to the traumatic impact, as
compared to adults. Half of the children with thoracic
trauma have a multisystem involvement. The initial
management of pediatric trauma is based on Advanced
Trauma Life Support (ATLS) principles. However, the
Address for correspondence: Dr. Subodh Kumar,
Department of Trauma Surgery, JPN Trauma Centre, All
India Institute of Medical Sciences, New Delhi, India.
E‑mail: subodh6@gmail.com
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,
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Website: www.jiaps.com For reprints contact: reprints@medknow.com

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

shown in Table 1. Associated injuries included spinal

Patients and Methods
Pediatric cases, of age less than or equal to 12 years, of
unusual neck and thoracic trauma that were prospectively
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 04/12/2024
injury in one, vertebral injury in one, and depressed
skull fracture with fracture femur in one. Three cases
had presented with a delayed presentation following

trauma; respiratory distress and incomplete quadriplegia

managed from April 2012 till March 2014 at a Level
1 trauma center were studied for the management
strategies and outcome.
Results
Six cases of unusual neck and chest wall trauma
were managed during this period. All cases were
managed as per the ATLS guidelines. Median age was
5.5 years (range 2–10 years). All six patients were boys.
2 weeks after trauma; esophageal perforation and
small tracheoesophageal fistula referred with a chest
tube 10 days after injury for further management,
and posttraumatic pyomyositis following chest wall
hematoma 3 days after road traffic accident as he fell
from the hands of his mother.
The other patient of tracheoesophageal injury was
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
the patient learnt to spit out his secretions by mouth. At
8‑months follow‑up, the computed tomography (CT) scan
showed a tracheoesophageal defect that was confirmed
on bronchoscopy as a defect of 4 cm [Figure 1a]. He
developed bradycardia on the operating table when
posted for a gastric pull‑up due to which the surgery
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was postponed. On further investigation, no cause could
be found, and it was hypothesized that the distended
cervical esophageal pouch had produced bradycardia
due to compression on the vagus nerve. The distended
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cervical esophagus measured 5 cm and had a kink on
preoperative ultrasonography. A redo gastroesophageal
junction dissociation, and retrosternal gastric pull‑up with
pyloric canal dilatation was done with esophagogastric
anastomosis in the neck [Figure 1b with insert]. The
anastomosis healed well in the immediate postoperative
period without any leak or stenosis. However, during
follow‑up, the patient presented with dysphagia due to
stricture of the esophagogastric anastomosis that was
revised at 26‑month follow‑up. The redundant cervical
esophagus was also excised.
The posttraumatic hospital stay varied from 5 to
38 days [Table 1]. The patient with an open chest wall
was repaired immediately, the subcutaneous tissue and
skin were closed as a delayed primary closure [Figure 2].
He could be discharged in 5 days. Four patients required
therapeutic artificial mechanical ventilation while one
was electively ventilated postoperatively. Two patients
on prolonged artificial ventilation and inotropes required
tracheostomy for better tracheal toileting. Both the
patients were successfully weaned off the ventilator,
kept on T‑piece for few days and decannulated before
discharge. Early complications were seen in five
b
Figure 1: (a) A computerized tomography scan of the chest showing a
wide traumatic tracheoesophageal defect. (b) Stomach mobilized and
pulled up to replace the esophagus and an esophagogastric anastomosis
done in the neck (insert)
12 Journal of Indian Association of Pediatric Surgeons / Volume 23 / Issue 1 / January-March 2018
patients [Table 1]. Operative interventions (1–3) were
required in five patients. The patient with vascular
injury of the neck developed hydrocephalus, for which a
ventriculoperitoneal shunt was put. He later had posterior
cerebral venous ischemic infarct as a later complication
due to massive hemorrhage from the vascular injury in
the neck and brain ischemia, leading to blindness. He
had a peripheral vision recovery at 3‑month follow‑up.
The other five patients are well. Hence, at a follow‑up
of 40–61 months, all 6 patients are alive.
Discussion
Thoracic injuries in children are not so common and
only about 10%–15% require operative intervention.[3]
Fortunately, the majority of thoracic trauma in children
requiring treatment is due to blunt trauma.[4] A high
index of suspicion is needed to suspect a dangerous
mechanism of injury. The compliant pediatric thorax
and pliable cartilage and bony thoracic cage enable the
chest to absorb a large amount of kinetic energy from
the impact, which is subsequently transferred to the
intrathoracic structures. Thus, often the child may have
major intrathoracic injury with minimal or no injury to
the thoracic bony cage comprising of the ribs, sternum,
and scapula. Thus, pulmonary contusion has been
reported as the most common thoracic injury that may
comprise up to 50% of the cases.[3,5]
Penetrating trauma constituting 15% of chest injuries in
children are seen most often in war‑hit countries, caused
by gunshots, knife wounds, and injury from other
sharp objects. In cases of penetrating pediatric neck
and chest trauma, there is great urgency as a relative
small blood volume loss can lead to hypovolemia and
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
a c
Figure 2: (a) Open chest wall showing a beating heart. (b) Computed
tomography scan done during the postoperative period. (c) Subcutaneous
tissue and skin were closed as a delayed primary closure
 Sharma, et al.: Pediatric thoracic trauma
wall of the internal jugular vein and during surgery
had travelled to the brachiocephalic vein due to the
negative venous pressure. It was very difficult to retrieve
the metallic piece from the pool of blood on the table.
The child had required massive blood transfusion, and
the subsequent complications were hemorrhagic shock,
and coagulopathy. While the cause of mortality in
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penetrating injuries is the penetrating injury itself, the
cause of mortality in half of the blunt trauma cases is
neurological injury.[3] The associated head injury is also
an important cause of mortality.
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Resuscitation of the child with thoracic trauma begins
with a survey for immediate life‑threatening injury.
Major thoracic injuries are known as the deadly dozen.[6]
The immediate life‑threatening thoracic injuries or lethal
six including airway obstruction, open pneumothorax,
tension pneumothorax, massive hemothorax, flail chest,
and cardiac tamponade should be identified in the
primary survey. The potential life‑threatening thoracic
injuries or hidden six including pulmonary contusion,
widened mediastinum/aortic transection, ruptured
tracheobronchial tree, ruptured diaphragm, esophageal
perforation, and myocardial contusion should not be
missed during the secondary survey. Out of the six cases
described here, two had life‑threatening emergencies,
whereas three had potential life‑threatening injuries.
The case of pyomyositis had also become a potential
life‑threatening injury due to the setting in of sepsis.
A thorough and focused evaluation for thoracic injuries
is required to discover the extent and severity of these
injuries.[7] Failure to promptly diagnose immediate
life‑threatening thoracic injuries and treat these injuries
results in exponentially increased morbidity and
mortality that may approach 50%.[2,7] Holmes et al.
reported the predictors of thoracic injury in children
sustaining blunt torso trauma as low systolic blood
pressure, elevated respiratory rate, abnormal results
on thoracic examination, abnormal chest auscultation
findings, femur fracture, and Glasgow Coma Scale score
of <15.[8]
A chest X-ray is sufficient in most cases. A CT
scan is advised only after stabilization to decide
the further course of management. Holscher et al.
concluded after comparing chest CT scan imaging
and chest radiographs that CT scan did not add to the
management of the trauma and increased the risk from
radiation.[9] In the case with lung laceration with spinal
injury, a diagnosis of miliary tuberculosis could be made
due to the presence of mediastinal lymphadenopathy
and pericardial effusion on CT scan and cervical spine
contusion on magnetic resonance imaging. He was
Journal of Indian Association of Pediatric Surgeons / Volume 23 / Issue 1 / January-March 2018
regularly monitored with echocardiography to assess the
heart function. He did not respond to prolonged higher
antibiotics but responded on initiation of antitubercular
treatment.
Less than 15% of cases of thoracic trauma in children
require thoracotomy. None of the cases described here
needed a formal thoracotomy, though multiple surgeries
were required including tracheostomy and neck and
abdomen exploration for gastric pull‑up.
Sequelae of pulmonary contusion in children include
pneumonitis and posttraumatic pseudocysts, as the
more elastic and pliable chest wall of children permits
the transmission of kinetic energy more efficiently to the
underlying lung parenchyma.[10] The concussive forces
of a high‑velocity impact with low displacement of the
chest wall result in a peripheral pseudocyst, whereas the
compressive forces of a low‑velocity impact with high
displacement of the chest wall resulting in a central
pseudocyst.[11] These typically resolve with antibiotics
and time.
Children presenting after blunt chest trauma may have
complete disruption of the airway with little external
sign of injury. The suspicion should be high in the
presence of pneumothorax and pneumomediastinum
that are refractory to adequate pleural drainage.[12]
Bronchoscopy is helpful to identify the location of
injury. Guided flexible bronchoscopy with intubation
distal to the injury was used to intubate the child with
tracheoesophageal fistula described here to give general
anesthesia. Advance preparation for a cardiopulmonary
bypass along with thoracotomy should be done in case
primary repair is contemplated.
In many instances with trivial tracheobronchial trauma,
the diagnosis may be missed. In a 10‑year review of
delayed diagnoses of traumatic tracheobronchial injuries,
the median time from initial presentation to diagnosis
was reported as 6 months.[13] Dyspnea (56%) and
pneumonia (39%) were the most common complaints.[13]
Bronchial sleeve resections or end‑to‑end anastomosis
can be performed safely in most situations.[13] There was
no difference in complications was observed between
parenchymal sparing procedures and resections.[13]
Early diagnosis of esophageal injury significantly
reduces the complications and mortality. Perforations
of the cervical esophagus can present with neck pain,
cervical dysphagia, dysphonia, or regurgitation of blood.
Intrathoracic perforations can rapidly contaminate
the mediastinum, leading to chest pain, tachycardia,
tachypnea, fever, and leukocytosis. Children are often
not able to communicate the symptoms, and sick look
of the child with painful respiration should raise the
13
 Sharma, et al.: Pediatric thoracic trauma
suspicion for further evaluation. A chest X-ray may
reveal mediastinal widening with or without an air‑fluid
level, subcutaneous emphysema, and a pleural fluid
collection. A lateral skiagram of the neck may reveal air
in the prevertebral fascial planes in cervical esophageal
perforation. On suspicion of an esophageal perforation,
a water‑soluble contrast study should be performed.
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A well‑contained leak can be managed with careful
observation, successful negotiation of a nasogastric
tube if feasible under guidance, keeping the patient
nothing by mouth, broad‑spectrum antibiotics, and total
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parenteral nutrition. A chest tube may be inserted if
there is thoracic collection. This may be progressed to
drip in feeds after 2 weeks. The contrast study may be
repeated after 3 weeks to check for the healing.
If the leak is not contained, the site of perforation
dictates further management. If the patient is stable
and the defect is less than 3 cm, the esophagus may
be explored. The upper‑ and mid‑esophagus are best
approached through the right side of the chest, whereas
the lower third of the esophagus and the esophagogastric
junction are best approached through the left side of
the chest. Some pleural or intercostal muscle covering
should accompany debridement and primary repair. Wide
drainage of both the mediastinum and pleural space is
mandatory. Video‑assisted thoracoscopic drainage for
esophageal perforation with mediastinitis in children has
been shown to be feasible and effective.[14]
In unstable patients, in the presence of inflammation
and infection, extensive injury, large tracheoesophageal
communication more than 3 cm and in cases with
life‑threatening tracheoesophageal injury as in one case
described here, a diversion procedure in the form of
cervical esophagostomy in emergency is lifesaving. This
may be followed by eventual esophageal replacement.
The case described here has a residual piece of
esophagus attached to the posterior wall of the trachea
and is in regular follow‑up to see for any complication.
The gastroesophageal junction had opened up as
demonstrated during the surgery for gastric pull‑up. The
gastroesophageal junction has now been disconnected
completely as high as possible through the abdomen.
He et al. described successful surgical management
of 3 cases including a 6‑year‑old child with huge
posttraumatic tracheoesophageal fistula (>5 cm in
length) with esophagus segment in situ as replacement
of the posterior membranous wall of the trachea.[15]
One of the cases had a posttraumatic pyomyositis
that presented as a soft‑tissue swelling over the chest
wall. Pyomyositis is a purulent infection of skeletal
muscle that arises from hematogenous spread, usually
14 Journal of Indian Association of Pediatric Surgeons / Volume 23 / Issue 1 / January-March 2018
with abscess formation.[16] Predisposing factors for
pyomyositis include immunodeficiency, trauma, injection
drug use, concurrent infection, and malnutrition.
Mechanical ventilation in children after chest trauma
requires a balance between sufficient ventilation and
the avoidance of barotrauma to the inflamed lung
parenchyma.[17] An elective tracheostomy was done
in two patients to support the lung toilet while on
ventilator. Tracheostomy in a child is a concern and
requires weighing the risks versus the merits.[18,19] With
sophisticated, patient‑friendly tracheostomy tubes, the
use may be extended to selected children in whom
prolonged ventilatory support more than 2 weeks is
anticipated.
It has been reported that regardless of the mechanism
of thoracic trauma, 15%–25% of children with thoracic
injury do not survive, depending on the severity of the
drainage of patients to the level of hospital.[20,21] The
mortality is around 5% for isolated thoracic trauma and
increases with concomitant injuries, up to 20%–25%
with abdominal, 30%–35% with head injuries, and 40%
with combined head, thorax, and abdominal injury.[20,21]
The mortality in thoracic injuries depends on the organ
involved. Peclet et al. reported that injuries to the heart
or great vessels had the highest mortality rate (75%),
followed by hemothorax (53%), lung laceration (43%),
and rib fracture (42%).[20]
Conclusion
About 75% of pediatric chest injuries worldwide are
caused by motor vehicle accidents, with the remainder
attributable to motorcycle‑related trauma, falls, and
bicycle accidents. These are thus preventable injuries.
Awareness on preventive aspects would help to prevent
a potential cause of morbidity and mortality.
There can be a varied presentation of life‑threatening
neck and chest wall trauma in children. Successful
management requires repeated evaluation and timely
appropriate decisions. The surgical options should
be considered appropriately without haste. The
life‑threatening cases described here were adequately
managed and survived. Even cases with a delayed
diagnosis and complications can be managed successfully
with a goal‑directed multidisciplinary team effort. All
pediatric surgeons should adopt the ATLS principles
religiously in the initial assessment and management of
traumatic cases to prevent immediate mortality and limit
morbidity.
Financial support and sponsorship
Nil.
 Sharma, et al.: Pediatric thoracic trauma
Conflicts of interest
There are no conflicts of interest.
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