in adults Hemothorax secondary to an injury of the great vessels usually results in death at the scene Hemothorax from injury to smaller vessels and pneumothorax have low mortality rates Goals of Treatment Immediate recognition and stabilization of airway, breathing, and circulation is crucial to management of pneumothoraces and hemothoraces Opening and then securing the airway with endotracheal intubation is the first step for a child with severe respiratory distress, inadequate oxygenation or ventilation, or depressed mental status after trauma Breathing may be supported via mechanical ventilation and evacuation of intrapleural air and blood Circulation may become impaired during tension physiology via obstruction of venous return, and evacuation of the pleura via needle or tube thoracostomy is immediately necessary Circulation may also be affected by blood loss into the thorax necessitating volume replacement with appropriate IVF and possible blood transfusion For the stable patient with pneumo- or hemothorax, the focus is on careful evaluation and treatment to prevent deterioration Chest radiograph (CXR) and ultrasound (US) may be helpful to identify the extent of the injury and the need for intervention Depending on the clinical progression, treatment may involve observation, tube thoracostomy, or surgical intervention Clinical Considerations Clinical Recognition Pneumothorax or hemothorax should be suspected in any child with a history of thoracic trauma who presents with chest pain, shortness of breath, respiratory distress, hypoxia, or evidence of shock Physical examination alone may be sufficient to make the diagnosis in patients with a large hemothorax or pneumothorax or severe complications such as tension physiology, but smaller lesions may be missed by examination alone All patients with a mechanism for a thoracic injury should undergo prompt radiologic evaluation with CXR, as an initial normal physical examination may be misleading Where available, bedside US can be used to augment the initial physical examination as it may facilitate identification of even small amounts of air or blood in the pleural space Triage Considerations Children with traumatic pneumothorax or hemothorax require immediate evaluation utilizing Advanced Trauma Life Support (ATLS) protocols and activation of the appropriate local trauma response In planning for a trauma response, preparations should be made for both needle aspiration of pleural air and placement of a chest tube, so that these procedures can be performed without delay if indicated by the patient’s clinical condition or diagnostic workup Clinical Assessment The child with suspected pneumothorax or hemothorax should undergo a thorough primary survey, looking for signs of compromised airway, breathing, or circulation Careful attention to vital signs, particularly tachycardia, tachypnea, and hypoxemia, may lead to discovery of impaired physiology not otherwise detected by physical examination It is important to recognize that due to children’s excellent vascular compensation abilities, hypotension is a late finding in pediatric shock and a normal blood pressure therefore does not rule out circulatory compromise Some patients with a pneumothorax may be asymptomatic Others may be tachypneic, complain of pleuritic chest pain, or be in severe respiratory distress Physical examination may be normal or may reveal diminished or absent breath sounds, crepitus, or hyperresonance to percussion on the side of the pneumothorax If a tension pneumothorax develops, findings may include tracheal deviation to the contralateral side and distended neck veins from impaired venous return to the heart through the deviated superior vena cava Some of these physical findings may be difficult to discern in a fully immobilized child in a noisy resuscitation room Patients with hemothorax may present in respiratory distress or profound shock secondary to obstruction of venous return or blood loss Decreased breath sounds are noted on the affected side, and there may be tracheal or mediastinal deviation Thirty percent to 40% of the patient’s blood volume may be rapidly lost in the pleural cavity with major vessel lacerations Bleeding from the intercostal or internal mammary arteries usually stops as systemic blood pressure falls and reexpansion of the lung may provide some tamponade effect Tension Pneumothorax A tension pneumothorax is the most common complicated intrapleural injury Tension pneumothorax develops in up to 20% of children after simple pneumothorax A tension pneumothorax occurs when there is progressive accumulation of air within the pleural cavity A laceration to the chest wall, pulmonary parenchyma, or tracheobronchial tree may function as a one-way valve, allowing air to enter but not leave the pleural space The progressive accumulation of air within the pleural cavity not only collapses the ipsilateral lung, but it also compresses the contralateral lung ( Fig 115.2 ) These patients may present in severe respiratory distress with decreased breath sounds on the side of the pneumothorax There is also a shift of the mediastinal structures to the contralateral side Two-thirds of the blood supply to the body is returned to the heart via the inferior vena cava Because the inferior vena cava is relatively fixed in place as it passes through the diaphragm and cannot shift as much as the superior vena cava, venous return to the heart is reduced FIGURE 115.2 Tension pneumothorax with a mediastinal shift Some patients with a pneumothorax or hemothorax demonstrate tension physiology: tachycardia and peripheral vasoconstriction If left untreated, this will progress to shock Initial treatment for tension physiology consists of needle decompression An immediate release of air should be noted with tension pneumothorax and the patient’s hemodynamic status should improve The needle decompression is only a temporizing measure and must be followed by tube thoracostomy Open Pneumothorax An open pneumothorax is the result of penetrating trauma There is a direct connection between the pleural space and the atmosphere, impeding ventilation As in a bronchial tear or lung parenchymal injury, air may enter but not leave the pleural space, creating a ball-valve effect Initial treatment includes placement of an occlusive dressing at the wound site This is best done when the patient is in full expiration A chest tube should be placed immediately to prevent development of a tension pneumothorax The chest tube should be inserted at a site different than the open wound Larger open chest wounds may need surgical closure Diagnostic Testing Chest Radiograph A CXR remains the most widely used test for the diagnosis of hemothorax and pneumothorax Both conditions are better visualized in the upright position than supine Plain radiographic signs of a pneumothorax may include identification of the pleural line, a hyperlucent hemithorax, pleural air at the lung base, and/or an unusually well-defined heart and mediastinal outline due to pleural air rising anteriorly A tension pneumothorax is indicated by the presence of midline shift to the contralateral side of the pneumothorax ( Fig 115.3 ) Smaller pneumothoraces may be better visualized by positioning the patient in the lateral decubitus position with the concerning side up Expiratory CXRs not add significantly to the evaluation Hemothorax on CXR may appear as blunting of the costophrenic angle, haziness or opacification of the hemithorax, or a visible air–fluid level Bedside Ultrasound Bedside US has become part of the standard assessment of trauma patients due to its ability to rapidly detect injuries and inform management strategies The major finding of pneumothorax is absence of lung sliding, while hemothorax is determined by the presence of fluid in the pleural space Studies in adults have shown the extended focused assessment with sonography for trauma (E-FAST) examination to be more sensitive in the detection of pneumothorax than supine radiographs with a sensitivity between 50% and 80% and specificity of 95% to 100% when compared to chest CT In the multiply injured or unstable patient, US may be particularly valuable in prioritizing further evaluation and interventions, particularly in adult patients ... that due to children’s excellent vascular compensation abilities, hypotension is a late finding in pediatric shock and a normal blood pressure therefore does not rule out circulatory compromise Some