The prognosis of traumatic asphyxia in childhood

A retrospective study of 51 pediatric cases of traumatic asphyxia

Background

Traumatic asphyxia (TA) is a rarely reported disease characterized as thoraco-cervico-facial petechiae, facial edema and cyanosis, subconjunctival hemorrhage and neurological symptoms. This study aimed to report 51 children of TA at the pediatric medical center of west China.

Methods

Scanned medical reports were reviewed and specific variables as age, sex, cause of injury, clinical manifestations and associated injuries were analyzed using SPSS 25.0.

Results

The average age of patients was 5.3 ± 2.9 (1.3–13.2) year-old. Thirty (58.8%) were boys and 21 (41.2%) were girls. Most TAs occurred during vehicle accident, object compression and stampede. All patients showed facial petechiae (100.0%, CI 93.0–100.0%), 25 (49.0%, CI 34.8–63.2%) out of 51 presented with facial edema, 29 (56.9%, CI 42.8–70.9%) presented with subconjunctival hemorrhage, including bilateral 27 and unilateral 2. Six patients had facial cyanosis (11.8%, CI 2.6–20.9%). Other symptoms were also presented as epileptic seizure, vomiting, incontinence, paraplegia, etc. The most frequent companion injury was pulmonary contusion (76.5%, CI 64.4–88.5%). Other companion injuries included mediastinal emphysema, fracture, cerebral contusion and hemorrhage, hypoxic-ischemic brain injury, abdominal organ contusion, mastoid hemorrhage, hematocele of paranasal sinuses, spinal cord injury, hepatic insufficiency, myocardial injury and retinal hemorrhage and edema. Treatment was mainly supportive. No death occurred in our study. The prognosis is rather good if without damage of central nervous system.

Conclusion

TA could bring out multiple symptoms, among which retinal hemorrhage and edema, spinal cord injury and viscera impairment have been less observed. Comprehensive physical and auxiliary examination should be performed considering TA. Its prognosis is rather good with focus on life-threatening complications.

Asphyxiation: a review

Asphyxia may be broadly defined as any condition that leads to tissue oxygen deprivation. This article reviews traumatic causes of asphyxia, including the syn drome known as traumatic asphyxia, where a crush injury to the thoracoabdominal area gives the striking clinical triad of cervicofacial cyanosis and oedema, subcon junctival haemorrhage and cutaneous petechial haemorrhages of the face, neck and upper chest. Other traumatic causes of asphyxia reviewed are strangulation due to hanging and autoerotic asphyxiation. However bleak the initial prognosis may appear, any patient who presents with a history of asphyxiation should initially be resuscitated according to the prioritized approach: airway with cervical spine control, oxygenation and ventilation, and circulation. The clinical appearance of the patient is not an indicator of outcome. The identification and treatment of associated compli cations and injuries is vital, since these are a major cause of morbidity and mortality if the patient survives the initial asphyxiation insult.

Isolated subconjunctival hemorrhages in nonaccidental trauma

PURPOSE

To establish child abuse as part of the differential diagnosis of isolated bilateral subconjunctival hemorrhages in infants.

METHODS

To review three cases of nonaccident trauma initially presenting with isolated bilateral subconjunctival hemorrhages as the only significant clinical finding.

RESULTS

Ophthalmic examination in cases 1 and 2 were entirely normal except for the large bilateral subconjunctival hemorrhages. Hematological parameters were normal in all three infants. Initial radiological findings were normal in case 1 but multiple healing rib fractures were identified when the chest X-ray was repeated 3 weeks later. Case 2 had skin and skeletal X-ray findings compatible with abuse at time of presentation to the ophthalmologist. Case 3 was admitted to hospital for multiple unexplained limb fractures but had been seen 2 weeks prior for poorly explained bilateral isolated subconjunctival hemorrhages and facial petechiae.

CONCLUSION

Nonaccidental trauma should be considered in the differential diagnosis of bilateral isolated subconjunctival hemorrhages in infants especially if associated with facial petechiae. These isolated subconjunctival hemorrhages may be part of the traumatic asphyxia syndrome caused by severe, prolonged compression of the child's chest and upper abdomen. Appropriate assessment includes a complete ophthalmic and pediatric examination as well as hematological testing and imaging studies. If the coagulation profile and initial imaging studies are normal yet there remains a high suspicion of abuse, an immediate nuclear scan or a repeat skeletal survey or chest film 2 weeks later is indicated.

The diagnosis and management of children with blunt injury of the chest

Thoracic trauma remains a major source of morbidity and mortality in injured children, and is second only to brain injuries as a cause of death. The presence of a chest injury increases an injured child's mortality by 20-fold. Greater than 80% of chest injuries in children are secondary to blunt trauma. The compliant chest wall in children makes pulmonary contusions and rib fractures the most common chest injuries in children. Injuries to the great vessels, esophagus, and diaphragm are rare. Failure to promptly diagnose and treat these injuries results in increased morbidity and mortality.

Practical points in evaluation and resuscitation of the injured child

The ultimate goal of resuscitation of an injured child is delivery of oxygen to intracellular organelles in order to maintain aerobic metabolism. This can be obtained by following ATLS protocols with immediate attention to the "ABCDE's" and compulsive reevaluation of the adequacy of resuscitation maneuvers. After stabilization, seriously injured children should be transferred to trauma centers with established pediatric trauma programs utilizing preexisting transfer agreements and protocols. Pediatric trauma is indeed a team endeavor, requiring the coordinated expertise and teamwork of prehospital EMS providers, trauma team members, and the pediatric trauma and rehabilitation centers. With careful and compulsive communication and coordination, injured children can be returned to their families in better mental and physical condition than pre-injury with reasonable expectation of a full and productive life.

A traumatic asphyxia in a child

PURPOSE

Traumatic asphyxia in a child is rare and the pathophysiology is different from that occurring in an adult. We report a case of traumatic asphyxia in a child who recovered without specific treatment, even though chest and abdominal compression was severe.

CLINICAL FEATURES

A three-year-old boy (14.2 kg) was run over by the rear wheel of a Jeep. He was under the tire for about three minutes and then was transferred to our hospital. When he arrived, he was lethargic with Glasgow Coma Scale of E3V4M6 (coma score of 13). He was cyanotic in his face and had a tire mark from the left shoulder to the right abdomen, petechiae on the head, face, conjunctiva and chest, oral bleeding, and facial edema. Serum concentrations of liver enzymes were increased and microhematuria was detected. However, no injuries were seen in the brain, eye, chest, or abdomen. Cyanosis disappeared in a few hours. Facial and thoracic petechiae disappeared in three days and that of the conjunctiva in five days. He was discharged from hospital on the 13th day without any disturbances.

CONCLUSION

We present a three-year-old boy with traumatic asphyxia. He had no complications although he received severe thoraco-abdominal compression by a Jeep.

Childhood trauma. Now and in the new millennium

Given the magnitude of childhood injuries that occur yearly in the United States, physicians need integrated echelons of care that include regional pediatric trauma centers, trauma centers with pediatric commitment, and EDs appropriate for children. Head injury is the most significant cause of morbidity and mortality among children, but physicians are far from effectively evaluating the dynamics of cerebral metabolism and oxygen delivery in the acute resuscitation of injured children. Critically injured children must be kept normothermic, and attention to the signs of hypovolemic shock must be monitored. Secondary brain ischemia frequently occurs because the details of resuscitation are not carefully monitored. A "leader" must be designated, and this should be someone experienced in childhood trauma. The younger the child and the more severe the injury, the more important is the notion of "experience." The ultimate goal, now and in the new millennium, should not be who, where, or when to administer care to critically ill or injured children but rather the quality of the treatment of these children.

Clinical evaluation of the child: injury to the chest and abdomen

In the paediatric age group (under 18 years) injury continues to be the dominant cause of mortality, being more common than all other causes combined. Disability resulting from injury represents a major expenditure in financial and emotional terms. The child’s anatomy and physiology are such that directly applying the principles of adult trauma care to the child can result in a less than optimal outcome and can add to long-term and/or permanent disability. Chest and abdominal injuries are the second and third most common causes of death, respectively, in childhood and when combined represent the second leading cause of death in this age group due to injury. There are six life-threatening injuries seen in paediatric injuries: airway obstruction, tension pneumothorax, massive haemothorax, open pneumothorax, flail chest and cardiac tamponade. There are six other potentially life-threatening injuries: simple pneumothorax, pulmonary contusion, tracheobronchial disruption, blunt cardiac injury, aortic disruption and haemothorax. These entities are discussed in terms of identification and treatment.

Abdominal injuries are generally well recognized by trauma surgeons. The difference in the paediatric age group involves the diagnosis of intra-abdominal injuries. The principle of diagnosis is that the injured organ should be specifically identified, not just left at the impression that something is bleeding, perforated or otherwise disrupted. The main diagnostic modality is the spiral or helical computerized tomography scan. This is an appropriate diagnostic method in all but the most severely injured and haemodynamically abnormal children. Care in initial assessment and management and in specific diagnosis has great potential to decrease the mortality in a country’s youngest citizens.

Abdominal aortic aneurysm presenting as meralgia paraesthetica

A case of abdominal aortic aneurysm is reported in a patient with long standing low back pain, presenting as meralgia paraesthetica and an increase in the severity of back pain. The case highlights the need for objective assessment of new symptoms arising in a chronic condition, and for a systematic approach to the assessment of radiographs performed in the accident and emergency department.

Traumatic asphyxia in children

Two cases of traumatic asphyxia in young children are reported. The first was a 2 year old child run over at low speed by the front wheels of a delivery van. He made an uncomplicated recovery. The second child was pinned to the floor by an empty chest of drawers in an unwitnessed accident. He was discovered in cardiac arrest and resuscitation was unsuccessful. The outcome following traumatic asphyxia is a product of duration of compression and the weight involved. Considerable weight can be tolerated for a short period, whereas a comparatively modest weight applied for a longer period may result in death.

Traumatic asphyxia compounding craniofacial trauma

Traumatic asphyxia is a condition characterized by cervicofacial petechiae, subconjunctival ecchymosis and other possible accompanying problems particularly ophthalmic, thoracic and cardiovascular injuries. While the facial petechiae per se are of little consequence, the attendant injuries to other organ systems can be serious and even fatal. Craniofacial injuries also present with fatal ecchymosis and haematoma formation due to the underlying skeletal injuries which may require active management. Clinicians managing trauma patients should be well aware of these two different entities which may occur separately or simultaneously so as to ensure correct and adequate treatment.

The Hillsborough tragedy

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Traumatic asphyxia: an indicator of significant pulmonary injury

Traumatic asphyxia has often been described as a rare syndrome with little prognostic significance. In the authors' series, however, all cases secondary to deceleration injury or compression of the anterior thorax were associated with pulmonary injury. The signs of venous congestion of the face and anterior thorax are not always recognized in the emergency department where they should be most clinically evident. Increased awareness of this syndrome by emergency physicians will result in better reporting and understanding of its clinical implications.

Proptosis and diplopia following traumatic asphyxia

We describe a previously unreported complication of traumatic asphyxia. An 11-year-old boy developed proptosis and diplopia following a crush injury in an automatic garage door. Computed tomography scan confirmed displacement of the eye. There was no retrobulbar hemorrhage or skull fracture, and the proptosis appeared secondary to traumatic displacement of orbital fat. Proptosis and diplopia resolved completely over six weeks. Visual disorders may be overlooked as a complication of trauma.