Pediatric emergency medicine trisk 1016

Ocular Chemical Injury
Spector J, Fernandez WG. Chemical, thermal, and biological ocular exposures.
Emerg Med Clin North Am 2008;26(1):125–136.
Vajpayee RB, Shekhar H, Sharma N, et al. Demographic and clinical profile of
ocular chemical injuries in the pediatric age group. Ophthalmology
2014;121(1):377–380.


CHAPTER 124 ■ THORACIC EMERGENCIES
JOY L. COLLINS, MERCEDES M. BLACKSTONE

INTRODUCTION
Thoracic emergencies in children often result in life-threatening alterations in
cardiorespiratory physiology. A rapid, yet organized, approach to the child with a
thoracic emergency is essential. The purpose of this chapter is to describe
nontraumatic surgical diseases of the thorax and guide the evaluating healthcare
provider in the diagnosis and treatment of these conditions. Congenital
abnormalities that are usually diagnosed at birth are not included. Thoracic
trauma is discussed in Chapter 115 .
This chapter reviews the pathophysiology and clinical manifestations of
thoracic emergencies, as well as the general principles of physical and laboratory
assessment. Subsequent sections cover specific entities within the following
categories: (i) airway obstruction, (ii) violations of the pleural space, (iii) intrinsic
pulmonary lesions, (iv) mediastinal tumors, (v) diaphragmatic defects, and (vi)
chest wall tumors.

GOALS OF EMERGENCY THERAPY
Children with thoracic emergencies present with a spectrum of processes and
severities. Because of the potential for thoracic emergencies to be serious and
even life threatening, a rapid but organized approach to the assessment and
treatment of these patients is crucial. Providers should rapidly address respiratory

and hemodynamic compromise, and identify those entities that require prompt
surgical consultation in the ED.
KEY POINTS


Respiratory function requires flow of air along a pressure gradient into
the tracheobronchial tree. Any compressive or obstructive force can
compromise this process, resulting in a thoracic emergency.
The emergency clinician evaluating the child with a thoracic problem
must attempt to determine whether the patient has evidence of airway
compromise, circulatory compromise, or components of both.
Thoracic conditions of surgical significance frequently present as a
result of a mechanical or infectious complication of an underlying
anatomic abnormality . These anatomic abnormalities may be grouped
into conditions resulting in airway compromise, violations of the pleural
space, intrinsic lesions of the lung, mediastinal masses, and
diaphragmatic defects.
Exceptions include pneumothorax and empyema, which can present in
previously healthy children and which require prompt detection and
treatment.
RELATED CHAPTERS
Signs and Symptoms:
Foreign Body: Ingestion and Aspiration: Chapter 32
Pain: Back: Chapter 54
Pain: Dysphagia: Chapter 56
Respiratory Distress: Chapter 71
Stridor: Chapter 75
Wheezing: Chapter 84
Medical, Surgical, and Trauma Emergencies
Infectious Disease Emergencies: Chapter 94

Pulmonary Emergencies: Chapter 99
Thoracic Trauma: Chapter 115
Procedures: Chapter 130
Ultrasound: Chapter 131
The Children’s Hospital of Philadelphia Clinical Pathway


Clinical Pathway for Evaluation and Treatment of Child With
Community-Acquired Pneumonia
URL: />Authors: J. Gerber, MD, PhD; T. Metjian, PharmD; M. Siddharth, MD; D.
Davis, MD, MSCE; T. Florin, MD; J. Zorc, MD; T. Kaur, MD; T. Blinman,
MD; D. Mong, MD; X. Bateman, CRNP; E. Pete Devon, MD; Ron
Keren, MD, MPH; L. Bell, MD; L. Utidjian, MD; E. Moxey, RN, MPH
Posted: September 2012, revised December 2019

CLINICAL MANIFESTATIONS
Physical Examination
Evaluation of the child with a thoracic emergency requires a calm, orderly
assessment of airway, breathing, and circulation (ABCs). In assessing the airway,
the physician must evaluate the adequacy of air movement and gas exchange.
Pulse oximetry should be performed upon the patient’s arrival. Anxiety or
confusion in a patient with a thoracic emergency may be evidence of hypoxemia.
Increased work of breathing may indicate partial airway obstruction and can be
evaluated by assessing the use of intercostal, subcostal, and supraclavicular
accessory muscles. Prolonged use of these accessory muscles may result in
fatigue and the most common cause of cardiac arrest in children—respiratory
arrest.
Breathing is best evaluated by palpation and auscultation of the chest. The
trachea should be palpated to ensure it is midline. Any lateralization of the
trachea is suggestive of either unilateral volume loss or a lateral space-occupying

process, such as a pneumothorax, pleural effusion, or mass. The neck and chest
should be palpated for signs of subcutaneous emphysema, suggestive of a
pneumothorax or airway injury with an air leak. Finally, breath sounds should be
assessed via auscultation for symmetry and adequacy of inspiratory and
expiratory airflow.
Evaluation of the cardiovascular system should include an assessment of the
patient’s pulse for quality, rate, and regularity. The peripheral skin should be
assessed for color, temperature, and capillary refill. Signs of poor perfusion often
precede that of pressure instability. The neck should be assessed for signs of
jugular venous distension. Finally, the heart should be examined for signs of