Tracheobronchial injuries are difficult to diagnose in children, and may be indicated by the presence of subcutaneous air, pneumomediastinum, or persistent air leak following tube thoracostomy for pneumothorax In patients with suspected tracheal injury, endotracheal intubation should be performed under bronchoscopic guidance in the operating room when possible, to avoid converting a partial tracheal injury to a full tear Symptoms of esophageal injury will depend on the region that perforates, and symptoms may therefore refer to the neck, chest, back, or abdomen Delay in diagnosis has a significant impact on morbidity and mortality While the finding of abdominal contents in the chest on radiograph is specific for diaphragmatic rupture, it is insensitive, and this injury must be considered any time there is significant blunt force to the abdomen or penetrating injury to the chest The findings of traumatic asphyxia are dramatic, but patients who survive the initial injury are most at risk from associated intra-abdominal and intrathoracic injuries Tracheobronchial Injuries Injury to the tracheobronchial tree in children occurs rarely, with an incidence of less than 1% of injured children This injury typically results from a high-energy mechanism or a focused direct blow Major vessels or pulmonary parenchyma are more likely to be injured in penetrating trauma than the tracheobronchial tree Cervical tracheal rupture may be caused by a direct blow to the trachea or violent flexion and extension of the patient’s head This whiplash effect can cause a tear between two cartilaginous rings Lower tracheobronchial injury usually occurs from a sudden increase in intrabronchial pressure Because the child’s chest wall is elastic, the trachea and main bronchi can be compressed between the chest wall and the vertebral spine Compression of the chest against a closed glottis can cause a sudden increase in intrabronchial pressure, resulting in a tracheobronchial tear Shear forces, traction, and crushing the airway between the chest and vertebral column may also cause a tracheobronchial injury Approximately 80% of tracheobronchial injuries occur on the posterior wall of the airway within cm of the carina