Significant thoracic trauma in the pediatric population is relatively uncommon, accounting for only 4% to 6% of children admitted to pediatric trauma centers, although this proportion may be higher in level centers Despite a high rate of scene fatalities, mortality rates for children who reach the hospital with isolated thoracic trauma are low; this rate triples when thoracic trauma occurs concurrently with head or abdominal trauma Blunt trauma occurs far more frequently than penetrating trauma and lung injuries outnumber those to the heart and great vessels Emergency evaluation requires careful observation and examination for evidence of impaired respiration or circulation, including any abnormal vital signs Be prepared to immediately secure the airway and support breathing and circulation Most thoracic injuries not require intervention and those that most commonly require only tube thoracostomy RELATED CHAPTERS Signs and Symptoms Cyanosis: Chapter 21 Neck Stiffness: Chapter 49 Pain: Chest: Chapter 55 Pain: Dysphagia: Chapter 56 Respiratory Distress: Chapter 71 Stridor: Chapter 75 Wheezing: Chapter 84 Medical, Surgical, and Trauma Emergencies A General Approach to the Ill or Injured Child: Chapter Airway: Chapter Child Abuse/Assault: Chapter 87 Abdominal Trauma: Chapter 103 Musculoskeletal Trauma: Chapter 111 Neck Trauma: Chapter 112 Neurotrauma: Chapter 113 Procedures: Chapter 130 Ultrasound: Chapter 131 The Children’s Hospital of Philadelphia Clinical Pathway ED Pathway for Evaluation/Treatment of Children With Physical Abuse Concerns URL: https://www.chop.edu/clinical-pathway/abuse-physical-clinicalpathway Authors: J Wood, MD; C Christian, MD; N Stavas, MD; C Jacobstein, MD; M Joffe, MD; J Lavelle, MD; P Scribano, DO Posted: November 2010, last revised September 2018 FIGURE 115.1 Algorithm showing approach to blunt thoracic trauma AP: anterior-posterior; CT: computed tomography; CXR: chest x-ray; ECG: electrocardiogram; ED: emergency department; e-FAST: Extended Focused Assessment with Sonography in Trauma; OR: operating room; PA: posterior-anterior; PTX: pneumothorax; TEE: transesophageal echocardiography; US: ultrasound (Reproduced with permission from: Nekhendzy V Anesthesia for head and neck surgery In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA (Accessed on 5/21/2019.) Copyright © 2019 UpToDate, Inc For more information visit www.uptodate.com ) PNEUMOTHORAX AND HEMOTHORAX CLINICAL PEARLS AND PITFALLS Pneumothorax is one of the most common injuries seen in thoracic trauma The unstable patient with suspected tension pneumothorax requires emergent needle decompression, even before radiologic evaluation, followed by tube thoracostomy The stable pediatric patient with suspected thoracic trauma may be assessed by chest radiography and bedside ultrasound (US) Computed tomography (CT) imaging may not be required Tube thoracostomy is recommended for patients with pneumothoraces that are large, associated with respiratory compromise, or when air transport is required Positive pressure ventilation by itself is not an indication for tube thoracostomy in patients with a small pneumothorax detected on CT only Hemothorax can lead to both respiratory and circulatory compromise, as a large volume of blood can be lost into the pleural space Treatment of hemothorax includes tube thoracostomy and support of circulation with both crystalloid products and blood transfusion as needed Current Evidence Pneumothorax is the second most commonly encountered injury in blunt thoracic trauma and the most common in penetrating thoracic trauma Air within the pleural cavity can arise from penetration of the chest wall, disruption of the lung parenchyma, a tear of the tracheobronchial structures, or esophageal rupture Hemothorax is much more common in penetrating than blunt thoracic trauma In blunt thoracic trauma, a hemothorax can occur from rib fractures lacerating the lung, pulmonary parenchymal injuries unrelated to rib fractures, lacerations of the chest wall vessels, or disruption of the vascular structures in the mediastinum or hilum The most common cause of a hemothorax is injury to the intercostal or internal mammary arteries, whereas injury to the lung or great vessels is less common but more significant Intraperitoneal hemorrhage may lead to a hemothorax if associated with disruption of the diaphragm Air and fluid within the pleural space more easily shift the mediastinum in children, compromising venous return and cardiac output to a greater extent than ... AP: anterior-posterior; CT: computed tomography; CXR: chest x-ray; ECG: electrocardiogram; ED: emergency department; e-FAST: Extended Focused Assessment with Sonography in Trauma; OR: operating... needle decompression, even before radiologic evaluation, followed by tube thoracostomy The stable pediatric patient with suspected thoracic trauma may be assessed by chest radiography and bedside