Pediatric emergency medicine trisk 924

Significant thoracic trauma in the pediatric population is relatively
uncommon, accounting for only 4% to 6% of children admitted to
pediatric trauma centers, although this proportion may be higher in
level 1 centers.
Despite a high rate of scene fatalities, mortality rates for children who
reach the hospital with isolated thoracic trauma are low; this rate triples
when thoracic trauma occurs concurrently with head or abdominal
trauma.
Blunt trauma occurs far more frequently than penetrating trauma and
lung injuries outnumber those to the heart and great vessels.
Emergency evaluation requires careful observation and examination for
evidence of impaired respiration or circulation, including any abnormal
vital signs.
Be prepared to immediately secure the airway and support breathing
and circulation.
Most thoracic injuries do not require intervention and those that do
most commonly require only tube thoracostomy.
RELATED CHAPTERS


Signs and Symptoms
Cyanosis: Chapter 21
Neck Stiffness: Chapter 49
Pain: Chest: Chapter 55
Pain: Dysphagia: Chapter 56
Respiratory Distress: Chapter 71
Stridor: Chapter 75
Wheezing: Chapter 84
Medical, Surgical, and Trauma Emergencies
A General Approach to the Ill or Injured Child: Chapter 7
Airway: Chapter 8

Child Abuse/Assault: Chapter 87
Abdominal Trauma: Chapter 103
Musculoskeletal Trauma: Chapter 111
Neck Trauma: Chapter 112
Neurotrauma: Chapter 113
Procedures: Chapter 130
Ultrasound: Chapter 131
The Children’s Hospital of Philadelphia Clinical Pathway
ED Pathway for Evaluation/Treatment of Children With Physical
Abuse Concerns
URL: />Authors: J. Wood, MD; C. Christian, MD; N. Stavas, MD; C.
Jacobstein, MD; M. Joffe, MD; J. Lavelle, MD; P. Scribano, DO
Posted: November 2010, last revised September 2018


FIGURE 115.1 Algorithm showing approach to blunt thoracic trauma. AP: anterior-posterior;
CT: computed tomography; CXR: chest x-ray; ECG: electrocardiogram; ED: emergency
department; e-FAST: Extended Focused Assessment with Sonography in Trauma; OR:
operating room; PA: posterior-anterior; PTX: pneumothorax; TEE: transesophageal
echocardiography; US: ultrasound. (Reproduced with permission from: Nekhendzy V.
Anesthesia for head and neck surgery. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
(Accessed on 5/21/2019.) Copyright © 2019 UpToDate, Inc. For more information visit
www.uptodate.com .)

PNEUMOTHORAX AND HEMOTHORAX


CLINICAL PEARLS AND PITFALLS
Pneumothorax is one of the most common injuries seen in thoracic
trauma.

The unstable patient with suspected tension pneumothorax requires
emergent needle decompression, even before radiologic evaluation,
followed by tube thoracostomy.
The stable pediatric patient with suspected thoracic trauma may be
assessed by chest radiography and bedside ultrasound (US).
Computed tomography (CT) imaging may not be required.
Tube thoracostomy is recommended for patients with pneumothoraces
that are large, associated with respiratory compromise, or when air
transport is required.
Positive pressure ventilation by itself is not an indication for tube
thoracostomy in patients with a small pneumothorax detected on CT
only.
Hemothorax can lead to both respiratory and circulatory compromise,
as a large volume of blood can be lost into the pleural space.
Treatment of hemothorax includes tube thoracostomy and support of
circulation with both crystalloid products and blood transfusion as
needed.

Current Evidence
Pneumothorax is the second most commonly encountered injury in blunt thoracic
trauma and the most common in penetrating thoracic trauma. Air within the
pleural cavity can arise from penetration of the chest wall, disruption of the lung
parenchyma, a tear of the tracheobronchial structures, or esophageal rupture.
Hemothorax is much more common in penetrating than blunt thoracic trauma. In
blunt thoracic trauma, a hemothorax can occur from rib fractures lacerating the
lung, pulmonary parenchymal injuries unrelated to rib fractures, lacerations of the
chest wall vessels, or disruption of the vascular structures in the mediastinum or
hilum. The most common cause of a hemothorax is injury to the intercostal or
internal mammary arteries, whereas injury to the lung or great vessels is less
common but more significant. Intraperitoneal hemorrhage may lead to a

hemothorax if associated with disruption of the diaphragm.
Air and fluid within the pleural space more easily shift the mediastinum in
children, compromising venous return and cardiac output to a greater extent than