Full text of DOI:10.1007/BF03027962

CLINICAL REPORT
1099
A traumatic asphyxia in
a child
Tomoki Nishiyama MD PhD,
Kazuo Hanaoka MD PhD
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, petechia 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
petechia 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.
Objectif : L’asphyxie traumatique, rare chez l’enfant, présente une physiopathologie différente de celle de
l’adulte. Nous citons le cas d’un enfant qui a subi une asphyxie traumatique et qui a récupéré sans traitement par-
ticulier, même avec une compression thoracique et abdominale sévère.
Éléments cliniques : Un garçon de 3 ans, (14,2 kg) a été écrasé sous une roue arrière d’un Jeep. Il s’est retrou-
vé sous le pneu pendant environ 3 min et a été conduit, par la suite, à notre hôpital. À son arrivée, il était
léthargique et présentait une cote de E3V4M6 à l’échelle de Glasgow (score de coma de 13). Son visage était
cyanosé et il avait une marque de pneu allant de l’épaule gauche à la partie droite de l’abdomen, des pétéchies à
la tête, au visage, sur la conjonctive et la poitrine, un saignement buccal et un œdème facial. Les concentrations
sériques d’enzymes hépatiques étaient augmentées et on a détecté une microhématurie. Cependant, aucune
lésion n’a été observée au cerveau, aux yeux, au thorax ou à l’abdomen. La cyanose est disparue en quelques
heures, les pétéchies faciales et thoraciques en trois jours et celles de la conjonctive en cinq jours. L’enfant a pu
e
quitter l’hôpital au 13 jour et ne présentait aucun trouble.
Conclusion : Nous avons cité le cas d’un enfant de 3 ans qui a souffert d’asphyxie traumatique. Il n’a pas présen-
té de complications même s’il a subi une sévère compression thoraco-abdominale.
From the Department of Anesthesiology, the University of Tokyo, Faculty of Medicine, 7-3-1, Hongo, Bunkyo- ku, Tokyo, 113-8655 Japan.
Address correspondence to: Tomoki Nishiyama MD PhD, 3-2-6-603, Kawaguchi, Kawaguchi-shi, Saitama, 332- 0015, Japan. Phone: 81-3-
5800-8668 (Dept.), 81-48-258-4911 (home); Fax: 81-3-5800-8938 (Dept.), 81-48-258-4911 (home); E-mail: nishiyam@ims.u-tokyo.ac.jp
Accepted for Publication July 27, 2000.
CAN J ANESTH 2000 / 47: 11 / pp 1099–1102

1100
CANADIAN JOURNAL OF ANESTHESIA
RAUMATIC asphyxia is a rare syndrome
caused by chest compression and was first
described by Ollivier.1 Clinically, it is char-
acterized by subconjunctival hemorrhage,
T
facial edema, cyanosis, and petechia on the upper
chest and face.1 Traumatic asphyxia in children differs,
in pathophysiological aspects, from that seen in adults
because of the greater elasticity of the thorax in chil-
dren.2 We report a child with traumatic asphyxia who
recovered without specific treatment, even though
chest and abdominal compression was severe.
Case report
A three-year-old boy (14.2 kg) with a history of asthma
was run over by the rear wheel of a Jeep. He was under
the rear tire for about three minutes and cried. He was
taken immediately to our hospital by ambulance and
received no treatment other than oxygen by face mask
before reaching the hospital. On arrival, he was lethar-
gic with Glasgow Coma Scale of E3V4M6 (coma score
of 13). His blood pressure was 80/50 mmHg, heart
rate 108 beats·min– 1, and respiratory rate 32
breaths·min–1. He had facial cyanosis and had a tire
mark from the left shoulder to the right abdomen,
petechia on the head, face, conjunctiva and chest, oral
bleeding, and facial edema (Figure). Blood gas analysis
just after he was brought to the intensive care unit was:
pH 7.38, PaCO 40.4 mmHg, PaO 370.3 mmHg,
base excess -1.3 2mMol·L–1 breathing25 L·min–1 100%
oxygen by a face mask. Increased white blood cell count
–3
(19,600 counts·mm ), aspartate aminotransferase
(AST, 430 IU·L– 1) and alanine aminotransferase (ALT,
246 IU·L– 1) were seen on blood examination.
Microhematuria was detected. Cervical, chest and
abdominal X-ray and echography showed no injuries.
Hemorrhage and edema were not observed in the brain
by computed tomography. Ophthalmological examina-
tion, including fundoscopy, revealed no abnormalities.
He was observed in the intensive care unit without
specific treatment except for maintenance fluid and
monitoring of arterial blood pressure, electrocardio-
gram and central venous pressure. The cyanosis disap-
peared in a few hours. Facial and thoracic petechia
disappeared in three days and that of the conjunctiva in
five days. His consciousness gradually improved and he
became alert on the fourth day. Serum concentrations
of AST and ALT decreased to normal on the seventh
day (28 IU·L–1 AST and 27 IU·L–1 ALT). He com-
plained of right lumbar and leg pain on the sixth day
and X-ray showed a fracture of the right iliac bone for
which no treatment was necessary. He was transferred
to the ward on the second day and was discharged from
the hospital on the 13th day without any disturbances.
FIGURE Face (upper) and body (lower) of the child with trau-
matic asphyxia. Cyanosis, petechiae, and edema are seen in his
face. A tire mark is seen on his body.
Discussion
Cases of traumatic asphyxia are mainly a consequence
of motor vehicle crashes as in the present case. Other
causes include heavy machines, furniture and, rarely,
deep sea diving, epileptic seizures and asthma.1 The
typical range of the duration of compression is
between two and five minutes.3 The duration and the
weight of compression affect the outcome following
traumatic asphyxia. Considerable weight can be toler-
ated for a short period, whereas a comparatively mod-
est weight applied for a longer period may result in

Nishiyama & Hanaoka: TRAUMATIC ASPHYXIA
1101
death.4 In animal experiments, no animal survived
compression by five times its own weight for longer
than 10 min.5 This 14.2 kg child was under a vehicle
with a weight of more than 2000 kg (500 kg per
wheel), which was about 150 times (37.5 times if con-
sidering the weight per wheel) of his body weight, for
about three minutes. Although this resulted in con-
siderable compression, he recovered without any
sequella perhaps due to the short duration of the com-
pression and due to the elasticity of his chest. The
details of the compression were not known. In con-
sidering the tire mark the wheel might not stay on one
part but moved on the body for three minutes and this
may be another reason why the damage was so light.
One more important factor influencing the outcome
may be the orientation of the compression. In this
case, the tire mark was predominantly over the left
upper abdomen and left chest. This might spare the
constrictions of cardiac output and venous return such
that the child’s neurological status on arrival was very
good. If the wheel had rolled onto the midchest at
right angles to the long axis of the body, the result
might have been worse.
Petechia were seen only on the upper part of the
body. Petechia formation is thought to occur because
blood is forced out of the right atrium through the
valveless innominate and jugular veins into the head and
neck by positive pressure transmitted to the medi-
astinum from the compressed chest or upper
abdomen.6 This sudden increased pressure in small
venules and capillaries causes rapid dilatation and
minute hemorrhages, producing the petechia. Due to
the same mechanisms, visual disturbances occur in some
cases.7 Therefore, opthalmological follow up is impor-
tant. The present case had no opthalmological abnor-
malities revealed by fundoscopy.
The reason why cyanosis, petechia and edema are
confined to the upper part of the body may be because
the lower part of the body is protected from the elevat-
ed venous pressure by a series of valves.8 Alternatively,
increased airway pressure may compress or obliterate
the inferior vena cava to protect the lower part of the
body.9 Although cyanosis, petechia and edema were
seen only in the upper part of his body, serum concen-
trations of liver enzymes increased and hematuria was
observed in the present case. These abnormalities might
have resulted from direct abdominal compression, as
evidenced by the tire mark on the abdomen, and/or
increased venous pressure transmitted to liver and kid-
ney. He had no radiographic liver or renal injury neces-
sitating surgical treatment.
chest compression but no apparent edema was detect-
ed by computed tomography.
Traumatic asphyxia may also be complicated by
serious thoracic injuries including pneumothorax,
hemothorax, rib fractures or flail chest, and mediasti-
nal injuries, and head injuries.1 0 Even with those com-
plications, the mortality rate is usually low in
children.10 This child was also fortunate not to have
incurred more severe chest trauma, given the mecha-
nism of elastic chest cage.
At first we did not diagnose his right iliac fracture.
The boy had no complaints, perhaps due to bed rest
and depressed consciousness, and because it was diffi-
cult to confirm the fracture line of a small child on
plain pelvic radiographs. Examining physicians should
be aware that subtle associated injuries may be pre-
sent, especially in small children with disturbed con-
sciousness.
Usually the prognosis of traumatic asphyxia is good
with no long-term disability when the patients have no
complicated injuries,6 , 8 except that visual disturbance
may continue.7 The child in the present case had the
potential for serious injury, but recovered without any
impairment. In managing traumatic asphyxia, it is impor-
tant to pay particular attention to detect and treat com-
plicating injuries including opthalmological examination.
Acknowledgment
We would like to thank Professor Chingmuh Lee MD,
Department of Anesthesiology, University of
California Los Angeles School of Medicine, for his
helpful comments.
References
1 Lowe L, Rapini RP, Johnson TM. Traumatic asphyxia. J
Are Acad Dermatol 1990; 23: 972–4.
2 Meller JL, Little AG, Shermeta DW. Thoracic trauma in
children. Pediatrics 1984; 74: 813–9.
3 Fred HL, Chandler FW. Traumatic asphyxia. Am J Med
1960; 29: 508–17.
4
Campbell-Hewson G, Egleston CV, Cope AR. Traumatic
asphyxia in children. J Accid Emerg Med 1997; 14: 47–9.
5 Furuya Y. Experimental traumatic asphyxia - grades of
thoracic compression and mortality. Igaku Kenkyu
1981; 51: 117–9.
6 Gorenstein L, Blair GK, Shandling B. The prognosis of
traumatic asphyxia in childhood. J Pediatr Surg 1986;
21: 753–6.
7 Baldwin GA, Macnab AJ, McCormick AQ. Visual loss
following traumatic asphyxia in children. J Trauma
1988; 28: 557–8.
The boy was lethargic but recovered in four days.
Lethargy have been due to hypoxia or brain edema by
8 Landercasper J Cogbill TH. Long-term followup after
traumatic asphyxia. J Trauma 1985; 25: 838–41.

1102
CANADIAN JOURNAL OF ANESTHESIA
9 Thompson A Jr, Illescas FF, Chiu RC-J. Why is the
lower torso protected in traumatic asphyxia? A new
hypothesis. Ann Thorac Surg 1989; 47: 247–9.
10 Sarihan H, Abes M, Akyazici R, et al. Traumatic asphyx-
ia in children. J Cardiovasc Surg 1997; 38: 93–5.