from the heart, hilum, or lung Catheters can also be placed directly into the right atrium, helping with fluid resuscitation, and the thoracic aorta can be compressed, improving circulation to the brain and heart While pediatric data on emergency thoracotomy are limited, reports suggest it is more likely to be successful in penetrating than blunt trauma and in patients who are not bradycardic or hypotensive Current recommendations are that emergency thoracotomy may be appropriate in patients who had vital signs in the field but cardiac arrest on transport or in the ED, or patients who remain hemodynamically unstable despite appropriate resuscitation after thoracic trauma, if a thoracic or trauma surgeon is available within approximately 45 minutes Lifesaving interventions such as airway management, fluid resuscitation, and pericardiocentesis should not be delayed while waiting for emergency thoracotomy to be performed The pediatric patient with vital signs, but not responding to initial treatment such as tube thoracostomy and pericardiocentesis, is a candidate for thoracotomy in the operating room, rather than the ED OTHER INTRATHORACIC INJURIES Goals of Treatment Diaphragmatic, esophageal, and tracheobronchial disruptions are rare and are often overlooked in the initial evaluation of thoracic trauma The CXR may initially appear normal in 30% to 50% of diaphragmatic hernias When abnormal, the CXR may show a bowel gas pattern in the thoracic space, a displaced nasogastric tube, or an elevated hemidiaphragm, more common on the left than the right The patient may complain of chest pain or difficulty breathing The examination may be normal or show decreased breath sounds, respiratory distress, or a scaphoid abdomen Surgical exploration is indicated in all suspected cases because a diaphragmatic hernia does not improve without surgical correction Patients with esophageal and tracheobronchial disruptions may present with pneumomediastinum, subcutaneous emphysema, a continuous air leak following tube thoracostomy, or, for those patients with esophageal disruption, fever and gastric contents from the chest tube Bronchoscopy and/or esophagoscopy are indicated in suspected cases CLINICAL PEARLS AND PITFALLS