weekly question 7/12/2025

[Admin]

A restrained six-year old is involved in a high speed motor vehicle collision. They present to your trauma center complaining of chest pain. On physical exam they have a Glasgow Coma Score of 15, age appropriate vital signs, bruising of the anterior chest, bilateral equal breath sounds and 99% oxygen saturations on room air. Which of the following findings on plain chest radiograph should prompt computerized tomography (CT) in the management of this pediatric blunt trauma patient?

a abnormal mediastinal silhouette

b due to the mechanism of injury, bruising and pain, the patient should undergo chest CT regardless of chest radiograph findings

c pulmonary contusions

d pneumothorax

e first and second rib fractures

 

[Dr Lu]

A

 

[Abd El wahed]

A

 

[Hassan k]

A restrained six-year old is involved in a high speed motor vehicle collision. They present to your trauma center complaining of chest pain. On physical exam they have a Glasgow Coma Score of 15, age appropriate vital signs, bruising of the anterior chest, bilateral equal breath sounds and 99% oxygen saturations on room air. Which of the following findings on plain chest radiograph should prompt computerized tomography (CT) in the management of this pediatric blunt trauma patient?

a abnormal mediastinal silhouette

b due to the mechanism of injury, bruising and pain, the patient should undergo chest CT regardless of chest radiograph findings

c pulmonary contusions

d pneumothorax

e first and second rib fractures

A

 

[Admin]

correct answer
a abnormal mediastinal silhouette

Chest computerized tomography (CT) is frequently used as a screening tool in pediatric blunt thoracic trauma. No consensus exists regarding optimal utilization of chest CT for blunt pediatric trauma resulting in overuse, increased radiation exposure and expense. It is clear that chest CT scans increase the number of diagnosed intrathoracic injuries (e.g. pneumothorax, contusions, fractures) when used in blunt trauma. However, in patients with a normal chest radiograph, additional injuries identified on chest CT rarely result in a change in patient management and more importantly do not predict increased morbidity or mortality.

The incidence of traumatic aortic injury in blunt pediatric trauma is exceedingly low and estimated as less than 0.1%. The incidence is lowest in young children and increases in the later teenage years. In a recent single institution retrospective study by Golden of 1035 blunt pediatric traumas, the finding of a widened mediastinum on chest radiograph identified patients with intrathoracic vascular injury. Limiting chest CT scan to only those patients with an abnormal mediastinum on screening chest radiograph would have resulted in 80% fewer chest CT scans.

In this same study, chest CT diagnosed 30% more pulmonary contusions than the screening chest radiograph. But there was no difference in clinical management as a result of the contusions detected by chest CT scan. Furthermore, other authors have reported that the severity of lung contusion determined by chest radiograph better predicted impairments to oxygenation, ventilation and need for mechanical ventilation than chest CT.

In children with a pliable chest, rib fractures are thought to indicate a high degree of force - therefore some have extrapolated this may be associated with intrathoracic vascular injury. The data does not support screening chest CT in patients with rib fractures including those to the first and second ribs. In pediatric patients, first and second rib fractures are not associated with a greater incidence of aortic injury.