Violence competes with the economy as the number

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1 Pediatric and Adult Thoracic Trauma: Age-Related Impact on Presentation and Outcome Richard J. Peterson, MD, Joseph J. Tepas III, MD, Fred H. Edwards, MD, Niranjan Kissoon, MBBS, Pam Pieper, ARNP-CS MSN, and Eric L. Ceithaml, MD Departments of Surgery and Pediatrics, University of Florida Health Science Center, Jacksonville, Florida To assess the impact of age on presentation and outcome, 2,415 cases involving blunt and penetrating thoracic trauma over an 8-year period were reviewed retrospectively from a single level I trauma center. Of the 2,073 patients alive on arrival, 79 were 12 years of age or less (children), 137 were 13 to 17 years of age (adolescent), 1,742 were 18 to 59 years of age (adults), and 115 were 60 years of age or more (elderly). Chi-square analysis was performed relative to presentation (blunt versus penetrating), need for thoracotomy, and hospital mortality. Although blunt thoracic trauma comprised 64/79 of children (81%) and 90/115 of the elderly (78%), penetrating thoracic trauma was more common for adolescents 79/137 (58%) and adults (58%) (p < 0.05). There was no significant difference in need for thoracotomy among the four age groups after blunt thoracic trauma. For penetrating trauma, however, there was a significantly higher incidence of thoracotomy in children as compared with the other three age groups (p < 0.05). In conclusion: (1) injuries comprised a greater proportion of thoracic trauma in children and the elderly. (2) In this series, children with penetrating thoracic trauma underwent thoracotomy more frequently. (3) Hospital mortality appeared to be increased for the elderly. (4) Analyses of pediatric thoracic trauma must separate children from adolescent age groups. (Ann Thorae Surg ) Violence competes with the economy as the number one concern of the American public. From 1968 to 1991 gun-related deaths have risen 60% nationwide, whereas automobile-related deaths have declined 21% [1]. This changing pattern of trauma in the United States stimulated us to reevaluate the presentation and outcome of patients sustaining thoracic trauma. Although it has been assumed that differences exist regarding pediatric and adult thoracic trauma, analyses from single institutions have been limited. Moreover, previous reviews of pediatric data have commonly grouped younger children and adolescent patients together. Likewise, reports of thoracic trauma in adults frequently fail to differentiate the elderly from the remainder of the adult population. Cognizant of these differences, this study was conducted to analyze the impact of age on the presentation and outcome of thoracic trauma from a single institution. Material and Methods The adult and pediatric trauma experience of a level one trauma center serving Northeast Florida and Southern Georgia was reviewed. Data entered in separate adult and pediatric databases were compiled over an 8-year period from 1985 to Data collection was continuous through several revisions of the database variables re- Presented at the Thirtieth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 31-Feb 2, Address reprint requests to Dr Peterson, Division of Cardiothoracic Surgery, University of Florida, Health Science Center/Iacksonville, 653 W 8th St, Jacksonville, FL corded during the period of study. The pediatric database was a component of the National Pediatric Trauma Registry [2]. The ongoing collection and maintenance of data was performed by a dedicated nurse clinician and supervised by a trauma surgeon. Thoracic trauma was defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to 807.4, 860.xx to 863.xx and 875.xx [3]. An undefined number of patients died at the scene or before arrival at the trauma center [4]. Such cases were not registered in either the adult or pediatric trauma registry. Therefore, for the purposes of this study all patients who were dead on arrival or before admission were removed from the analysis. Likewise, patients treated as outpatients and released were not included in the analysis so as only to include patients with clinically relevant thoracic trauma. The analysis was performed by age groups. Patients 12 years of age or less were described as children and those 13 to 17 years of age were defined as adolescents. Those patients 18 to 59 years of age were defined as adults and those 60 years of age or more were described as elderly. Injuries were classified as either blunt or penetrating and further defined by mechanism of injury. Outcome was defined in terms of need for surgery (thoracotomy, laparotomy, or both) and mortality. Thoracotomy was defined as any thoracic surgical procedure (excluding tube thoracostomy). Repair of the diaphragm was accounted for as laparotomy, as virtually all diaphragmatic repairs in this study were performed from an abdominal approach. Those patients undergoing both thoracotomy and laparot-

2 Ann Thorae Surg PETERSON ET AL Number 81% CHILDREN (N=79) 19% -. 42% 58% ADOLESCENTS (N=I,742) 5 ~l b : 4 : l : l l l l l l l l42%-. l l r J : ~ ~ 78% ~ ~ ' " 0 5 W ~ w ~ ~ ~ ~ ~ m ~ w ~ m ~ ~ ~ ~ Age (Years) Fig 1. Age distribution of patients. Although this agedistribution is distinctly different from the general population, the curve essentially mirrors those describing the agedistribution of all injuries in general. omy were included in the thoracotomy subset. Statistical analysis was performed by y.. 58% ADULTS (N=1,742) (J 22% ELDERLY (N=115) Fig3. Relative incidence of blunt versus penetrating thoracic trauma by agegroup. Results Files of 14,076 patients registered over the 8-year period were available for analysis. Of these, 1,599 were pediatric (11%) and 12,477 were adult. Of the total cases registered, 2,415 were identified to have incurred significant chest injury (17%). Ages ranged from 2 months to 90 years (mean ± standard deviation, 32.2 ± 15 years) (Fig 1). Two hundred forty were pediatric and 2,175 were adult. Three hundred forty-two patients, 24 pediatric and 318 adult, died before admission and therefore, were removed from the study. This left 2,073 patients for analysis, 216 pediatric and 1,857 adult. Of these, 79 patients were 12 years of age or less, 137 were between the ages of 13 and 17, 1,742 were between the ages of 18 and 59, and 115 were 60 years of age or more (Fig 2). Although blunt trauma comprised 81% of the thoracic injuries in children and 78% of the injuries in the elderly, penetrating injuries were more common for the adoles- Fig 2. Breakdown of all patients with thoracic injury demonstrating derivation of each of the four agegroupsanalyzed. cents (58%) and adults (58%) (p < 0.05) (Fig 3). Mechanisms of injury were virtually the same for the adolescent and adults age groups. Although the percentage of blunt thoracic injuries was similar for children and the elderly, the mechanisms of blunt injury varied somewhat. Sixtynine percent of blunt thoracic trauma in the elderly was caused by motor vehicle collisions, with 11% related to pedestrian accidents, 11% falls, 3% bicycle, and 6% other. Children had a higher percentage of pedestrian injuries (35%) and bicycle injuries (14%) with 34% related to motor vehicle collisions, 11% falls, and 6% other mechanisms. There was no significant difference in the need for thoracotomy among the blunt thoracic injuries in any of the four age groups (Table 1). However, for penetrating chest trauma, the number of children undergoing thoracotomy was significantly higher as compared with the other three age groups (p < 0.05). Whereas the vast majority of penetrating thoracic trauma in the adolescent, adults, and elderly age groups related to gunshot wounds and stab injuries from assaults, children appeared to incur penetrating injuries from different mechanisms. Of the six penetrating thoracic injuries in children 12 years of age or less who underwent thoracic operation, two were farm related. One child was impaled on a rod while skateboarding. One student fell through a plate glass door and required a major thoracoabdominal operation. There was only one gunshot wound and one stab wound. Both were inflicted by siblings. Laparotomy was frequently performed for patients with penetrating trauma, but did not statistically differ between any age group (Table 1). Laparotomy was performed more frequently than thoracotomy in adolescent patients with penetrating thoracic trauma. There were a total of 21 diaphragmatic injuries in the entire series. These were evenly distributed, comprising 1% of each age group. Seventy-five percent of deaths in children with blunt injuries were related to central neurologic injury. Mortal-

3 16 PETERSON ET AL Ann Thorac Surg Table 1. Age Related Outcome (Operative Procedures) Thoracic Trauma Thoracic Trauma Age Group No. Thoracotomy Laparotomy No. Thoracotomy Laparotomy Children 64 5/64 (8%) 3/64 (5%)" 15 6/15 (40%)a 4/15 (27%) Adolescents 58 2/58 (3%) (21%)a (15%)a 17/79 (22%) Adults /729 (6%) 87/729 (12%)a /1013 (18%) 162/1013 (16%) Elderly (2%) 4/90 (4%)a (8%) 3/25 (12%) a p < 0.05 by Jl analysis between children and adolescent groups and between adult and elderly groups in laparotomy in blunt thoracic trauma, and between children and adolescent groups in thoracotomy in penetrating thoracic trauma. Laparotomy = all abdominal procedures (induding repair of diaphragm); No. = number of patients in each subgroup; thoracotomy = all thoracic-related operative procedures. ity from blunt thoracic trauma did not differ significantly between any age group, although there was a trend toward higher mortality in the elderly group (Table 2). Mortality for penetrating thoracic trauma in the elderly group (32%) was significantly higher than for the adults group (p < 0.001). Comment Various studies have reported broad differences in the presentation and outcome of thoracic trauma. An analysis of the literature lead us to expect that these differences might be explained by the differences in the ages of subjects reported in each study. Peclet and colleagues [5] proposed that pediatric chest injuries differ from adult chest trauma in the type of injuries seen, their mechanisms, and their outcomes. Several additional studies have implied differences regarding thoracic trauma between children and adolescents [6, 7]. Although these differences have been alluded to, formal analysis of the impact of age over the entire age range has not been undertaken. The current study evaluated the impact of age on the presentation and outcome of thoracic trauma in a large series from a single institution. The majority of children suffered blunt thoracic injuries. Previous series concentrating on children under the age of 12 reported primarily blunt thoracic trauma [7-11]. As in the current study, these injuries relate to accidents such as falls, motor vehicle collisions, pedestrian incidents, and bicycle accidents. There is a low general incidence of thoracotomy for blunt thoracic injury. However, Sivit and co-workers [12] found that significant unsuspected or underestimated thoracic injuries are relatively common in Table 2. Age-Related Mortality Age Group Children Adolescents Adults Elderly a p < by Jl analysis between elderly and adult groups. No. = No Thoracic Trauma 9/64 (14%) 4/58 (7%) 111/729 (15%) 19/90 (21%) total number of patients in each subgroup. Thoracic Trauma 1/15 (7%) 3/79 (4%) 66/1013 (7%)" 8/25 (32%)a children. This may be partly explained by the fact that the chest wall is more compliant in children [11, 13]. Most operations performed for patients with blunt thoracic trauma related to associated injuries [14]. In the pediatric groups 75% of deaths from blunt thoracic trauma were secondary to neurologic sequelae from central nervous system trauma. Roux and Fisher [9] reported 100 blunt thoracic injuries in pediatric patients with a mean age of 5.7 years. Seven of eight deaths reported had significant associated head injuries. Similar findings have been noted in other studies [5, 7, 10, 15]. Although neurologic injuries may dictate outcome, thoracic injuries may compromise ventilation and contribute to the morbidity of neurologic injuries. Indeed, mortality rates for children with both rib fractures and head injury have been reported even as high as 71% [16]. There are very limited reports of penetrating thoracic trauma in patients 12 years of age or less. In fact, the current study represents the largest penetrating pediatric trauma series in this age group from a single institution. Forty percent of the children with penetrating thoracic trauma underwent a thoracic operation. This is considerably higher than the 15% generally reported in the adult literature or the 18% of adults with penetrating trauma in the current series. The principles of management of chest trauma in children were similar to adults. However, because of differences in chest wall anatomy and intrathoracic size, penetrating thoracic trauma appears to require thoracotomy in children at a greater rate when these principles are applied [17]. The underlying mechanisms of injury also appeared to differ somewhat for children in our study and may have impacted the findings in this relatively small number of patients. Peclet and colleagues [5] reported a 66% (eight of 12 patients) rate of operation for pediatric patients with penetrating thoracic trauma. An age distribution was not reported in their series. While the report of chest injuries in childhood by Nakayama and co-workers [8] was comprised almost entirely of blunt thoracic injuries, two of the three penetrating injuries (66%) necessitated thoracic surgery. Meller and colleagues [6] reported a 20% (eight of 40 patients) operative rate. However, all but four of their patients were greater than 13 years of age. On the basis of our experience, it would seem that younger patients undergo thoracic surgical procedures more frequently than older patients. Neuro-

4 Ann Thorac Surg 1994;58:14--8 PETERSON ET AL 17 logic function in pediatric patients with penetrating thoracic trauma was essentially normal unless the patients sustained hypoxic central nervous system damage due to severe hemorrhagic shock. The majority of chest trauma injuries in adolescents were in the penetrating subgroup, primarily related to gunshot and stab wounds. This reflects increasing violence in this age group and perhaps reflects a slight bias toward an urban trauma center. Adolescents did not significantly differ from the adults in terms of presentation or outcome. The incidence of penetrating trauma was equal in both adolescent and adult age groups with roughly the same mechanisms accounting for these injuries. The need for surgical procedures and mortality were remarkably similar for the two age groups. The current study helps to explain how differences in composition of study groups based on age may alter the reported outcomes of pediatric thoracic trauma. In this study, adolescents underwent laparotomy more frequently than children. As in many centers, diagnostic peritoneal lavage was rarely performed in children. A difference in the surgical management of blunt abdominal injuries may also have accounted for this, in that children with blunt abdominal trauma were more frequently managed with observation. Adolescents required laparotomy more frequently than thoracotomy. Other pediatric series have also reported laparotomy rates higher than thoracotomy [7]. Meller and colleagues [6] reported a 26% rate of laparotomy in primarily adolescent patients after penetrating thoracic trauma. The 1% incidence of diaphragmatic injury in the current study is similar to that reported by Galan and colleagues (18] (2.3%) and by Smyth [10] (3%). Elderly patients had a significantly higher percentage of blunt versus penetrating thoracic injuries than adults. A higher percentage of injuries were related to falls and motor vehicle accidents, with fewer exposures to violent crimes. Although, the general incidence of operation was approximately similar to adults, the overall mortality was greater in the elderly population. In a study by Stellin [19], 40% of the 25 patients sustaining severe chest trauma who where over the age of 60 years died. Livingston and Richardson [20] noted that pulmonary function studies were markedly abnormal, averaging 40% to 50% of normal, shortly after severe thoracic trauma. Pulmonary function studies improved substantially in the ensuing 4 months. Perhaps the limited pulmonary reserve often present in the elderly population partially accounted for the increased mortality observed in this age group. Wisner [21] demonstrated that even minor chest wall trauma can be serious in elderly patients. In his study of patients greater than 60 years of age the use of epidural analgesia was an independent predictor of both decreased mortality and a decreased incidence of pulmonary complications. Gutman and colleagues [22] also demonstrated a higher incidence of intracranial mass lesions in motor vehicle victims over the age of 70 years compared with those less than 30 years old. In conclusion, analysis of data from a single level I trauma center revealed patient age had an impact on the presentation and outcome of blunt and penetrating thoracic trauma. thoracic trauma was more common than penetrating thoracic trauma in children and the elderly. Children with penetrating thoracic trauma underwent thoracic surgical procedures more frequently than patients in the other three age groups. This most likely related to differences in mechanism of injury, chest wall anatomy, and intrathoracic size, as the principles governing the need for surgical intervention were similar for all age groups. Therefore, analysis of pediatric thoracic trauma must separate children from adolescents, as their presentation and outcomes differ. Moreover, elderly patients have presentation and outcomes that differ from the adult population. References 1. Center for Disease Control and Prevention. Effectiveness in disease and injury prevention: deaths resulting from firearm and motor vehicle-related injuries; United States MMWR 1994;43: Tepas JJ, Ramenofsky ML, Barlow B, et al. National pediatric trauma registry. J Pediatr Surg 1989;24: ICD-9-CM. International Classification of Disease. Ann Arbor, MI, Commission on Professional and Hospital Activities, Bregman K, Spence L, Wesson D, Bohn D, Dykes E. Thoracic vascular injuries: a post mortem study. J Trauma 1990;30: Peclet MH, Newman KD, Eichelberger MR, Gotschall CS, Garcia VF, Bowman LM. Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg 1990;25:961-{j. 6. Meller JL, Little AG, Shermeta DW. Thoracic trauma in children. Pediatrics 1984;74: Rielly JP, Brandt ML, Mattox KL, Pokorny WJ. Thoracic trauma in children. J Trauma 1993;34: Nakayama DK, Ramenofsky ML, Rowe MI. Chest injuries in childhood. Ann Surg 1989;210: Roux P, Fisher RM. Chest injuries in children: an analysis of 100 cases of blunt chest trauma from motor vehicle accidents. J Pediatr Surg 1992;27: Smyth BT. Chest trauma in children. J Pediatr Surg 1979;14: Beaver BL, Laschinger [C. Pediatric thoracic trauma. Semin Thorac Cardiovasc Surg 1992;4:255-{) Sivit CJ, Taylor GA, Eichelberger MR. Chest injury in children with blunt abdominal trauma: evaluation with CT. Radiology 1989;171: Manson D, Babyn PS, Palder S, Bergman K. CT of blunt chest trauma in children. Pediatr Radiol 1993;23: Eichelberger MR, Mangubat EA, Sacco WI, Bowman LM, Lowenstein AD. Outcome analysis of blunt injury in children. J Trauma 1988;28: Clark GC, Schecter WP, Trunkey DO. Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion. J Trauma 1988;28: Garcia VF, Gotshall CS, Eichelberger MR, Bowman LM. Rib fractures in children: a marker of severe trauma. J Trauma 1990;30: Peterson RI, Tiwary AD, Kissoon N, Tepas JJ III, Ceithaml EL. Pediatric penetrating thoracic trauma: a five year experience. Pediatr Emerg Care 1994;10: Galan G, Penalver JC, Paris F, et al. chest injuries in 1696 patients. Eur J Cardiothorac Surg 1992;6: Stellin G. Survival in trauma victims with pulmonary contusion. Am Surg 1991;57: Livingston DH, Richardson JD. Pulmonary disability after severe blunt chest trauma. J Trauma 1990;30:562-{j. 21. Wisner DH. A stepwise logistic regression analysis of factors

5 18 PETERSON ET AL Ann Thorae Surg affecting morbidity and mortality after thoracic trauma: effect of epidural analgesia. J Trauma 1990;30: Gutman MB, Moulton RJ, Sullivan 1, Brown T, Hotz G, Tucker WS. Relative incidence of intracranial mass lesions and severe torso injury after accidental injury: implications for triage and management. J Trauma 1991;31: DISCUSSION DR RONALD C. ELKINS (Oklahoma City, OK): I think this is an excellent review and something that brings some specific points to mind. In terms of the management of the thoracic trauma in children who required thoracotomy, do you have any information concerning the length of hospital stay? Did they tend to resolve as quickly or to have more problems or fewer problems than those, say, in the adolescent or adult age group? DR PETERSON: The length of stay was directly related to type of injury and the presence of associated injuries. Length of hospital stay after blunt thoracic trauma related to the impact of associated injuries, primarily neurologic and orthopedic. Neurologic and severe orthopedic injuries were not commonly associated with penetrating thoracic trauma. As a rule, patients with penetrating thoracic trauma in all three of the age groups that you have mentioned had rather rapid recoveries and short hospital stays. DR IRVING L. KRON (Charlottesville, VA): There has been a nationwide tendency to have trauma handled by general trauma surgeons. Can you give us your opinion on who should be handling isolated thoracic trauma and justification? DR PETERSON: This series came from a level I trauma center where the cardiothoracic surgeons are integrated with the total trauma team. Our co-author, Dr Tepas, is a pediatric trauma surgeon who authored the Pediatric Trauma Score and is a director of the National Pediatric Trauma Registry. For the majority of thoracic trauma, I think it is appropriate for trauma surgeons to manage these patients. However, one cannot divorce involvement as a cardiothoracic surgeon, given that complex thoracic procedures and even cardiopulmonary bypass will always be required for a small subset of patients. The Society of Thoracic Surgeons: Thirty-first Annual Meeting Mark your calendars for the Thirty-first Annual Meeting of The Society of Thoracic Surgeons, which will be held at the Palm Springs Convention Center in Palm Springs, California, January 3D-February 1, Members may register for the Scientific Sessions at no charge. There will be a $250 registration fee for nonmember physicians except for Scientific and Poster Session presenters and residents. Registration for the Postgraduate Course is separate from the Annual Meeting. There will be a $65 registration fee for attendees of the Postgraduate Program, which will be held Sunday, January 29. The Postgraduate Course will provide in-depth coverage of thoracic surgical topics selected to enhance and broaden the knowledge of practicing thoracic and cardiac surgeons. Advance registration forms, hotel reservation forms, and details regarding transportation arrangements, as well as the complete meeting program, will be mailed to Society members this fall (1994). Nonmembers wishing to receive information on attending the meeting should write to the Society's Secretary, Richard P. Anderson. Richard P. Anderson, MD Secretary The Society of Thoracic Surgeons 401 N Michigan Ave Chicago, IL (312)

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