Penetrating thoracic trauma in children is less common than blunt trauma, accounting for 20% of pediatric thoracic injuries in one study The most common mechanisms of injury were gunshot wounds and stab wounds Unlike blunt thoracic trauma, where observation and supportive therapies are most common, penetrating thoracic trauma often requires invasive interventions The most common penetrating thoracic injuries are hemothorax and pneumothorax, almost always requiring tube thoracostomy More children with penetrating thoracic injury will require operative intervention because of the close proximity of the vital organs in the thoracic cavity in children, as compared with adults Evaluation and treatment includes airway stabilization, fluid resuscitation, and management of the chest wound Radiopaque markers (such as paper clips) may be placed by the entry and exit sites to help determine the course of the missile Pericardial tamponade should be considered and immediately treated in the unstable patient In the stable patient, transesophageal or transthoracic echocardiogram is helpful in evaluating the heart and determining if there is fluid within the pericardial sac Diaphragmatic lacerations are difficult to diagnose and may require exploratory laparotomy, thoracoscopy, or laparoscopy for diagnosis and treatment CLINICAL PEARLS AND PITFALLS Penetrating trauma remains uncommon in children, but confers a high mortality risk Presence of hemothorax, pneumothorax, or pericardial tamponade necessitates emergent tube thoracostomy or pericardiocentesis, respectively Many patients will also have involvement of the abdomen, which requires thorough evaluation Significant or fluid-resistant hypotension indicates the need for emergent thoracotomy Emergency Thoracotomy Emergency thoracotomy is the most aggressive resuscitative measure for patients with thoracic trauma With the advancement of transport systems and regionalization of trauma centers, patients who previously would have died at the scene are now surviving to arrival to trauma centers for evaluation and treatment Emergency thoracotomy allows the physician to evaluate and evacuate the pericardial sac, perform open cardiac massage, and temporarily control bleeding