pain or ipsilateral shoulder pain The presence of bowel sounds within the thoracic cavity is nonspecific because bowel sounds can be transmitted from the abdominal cavity in children More commonly, bowel sounds are absent because of the ileus that is typically associated with the injury A nasogastric tube may be difficult to pass in patients with a diaphragmatic injury and gastric herniation In left-sided diaphragmatic tears, the tip of the nasogastric tube may be seen looping into the chest Even though the diagnosis of diaphragmatic injury is usually made upon initial review of the CXR, some series have reported that up to 30% to 50% of initial films are normal Right-sided diaphragmatic injury and herniation is more difficult to diagnose because the herniated organs are more likely to be solid The chest x-ray may just show opacification of the right lung fields This emphasizes the importance of serial evaluations and CXRs in patients suspected of having a diaphragmatic injury Other diagnostic studies such as chest and abdominal CT scan with contrast or upper and lower gastrointestinal tract series can help confirm the diagnosis Before performing a tube thoracostomy for a pneumothorax or hemothorax, diaphragmatic injury should be considered to avoid injury to herniated intraabdominal organs In patients who clinically appear to have a diaphragmatic injury (scaphoid abdomen, bowel sounds auscultated in the thoracic cavity), a finger should be inserted in the thoracostomy incision site and the diaphragm should be palpated before placing a chest tube Herniation and strangulation of bowel may result from a delayed diagnosis Diaphragmatic defects will not spontaneously heal because of motion associated with respirations and cyclical tension Exploratory laparotomy or laparoscopy should be performed in cases where a diaphragmatic hernia is strongly suspected TRAUMATIC ASPHYXIA Traumatic asphyxia results from direct compression of the chest or abdomen The most common mechanism is a child run over by a slowly moving motor vehicle or pinned underneath a heavy object In anticipation of impending injury, the child may inspire, tensing the thoracoabdominal muscles and closing the glottis Traumatic asphyxia also occurs in patients with asthma, seizures, persistent vomiting, and pertussis Positive pressure is transmitted to the mediastinum, and blood is forced out of the right atrium into the valveless venous and capillary systems The clinical manifestations occur because the increase in pressure dilates the capillary and venous systems Areas drained by the superior vena cava are particularly affected, explaining the marked difference between the patient’s head and neck as opposed