Pediatric emergency medicine trisk 3692 3692

CHAPTER 115 ■ THORACIC TRAUMA
MATTHEW EISENBERG, JOY L. COLLINS

GOALS OF EMERGENCY THERAPY
The initial goals of emergency therapy for the child with thoracic trauma, just as
for all forms of major trauma, are assessment and stabilization of airway,
breathing, and circulation, all of which are at increased risk due to the location of
vital structures within the thorax. A thorough primary trauma survey, with
immediate steps to correct any deficits in airway, breathing, and circulation
before moving on to the next element of assessment, is critical. The provider
should be prepared to emergently intubate the trachea, provide mechanical
ventilation, administer both intravenous fluids (IVFs) and blood products, and
perform other emergency interventions such as thoracentesis, thoracostomy, and
pericardiocentesis as indicated.
Respiratory compromise in children with thoracic trauma may be due to
obstruction of the airway, injury to the chest wall, lung parenchyma, or central
nervous system, or shock. Thoracic hemorrhage, obstruction of venous return, or
direct injury to the heart may lead to circulatory compromise and shock.
The evaluation of the child with thoracic trauma is complicated by both
physical and developmental differences from adults. Detailed further in the
sections that follow, these include increased compliance of the thoracic cage,
greater susceptibility to air and fluid in the pleural space, a shorter, narrower
trachea at greater risk of obstruction, and greater sensitivity to hypoxia. Due to
fear, pain, separation from caregiver and/or young age, an injured child may not
be able to articulate his/her complaints or comply with the examination.
Therefore, attention to nonverbal cues, vital signs, and careful observation of
respiratory and circulatory status are crucial. Because approximately 80% of
thoracic trauma occurs as part of a multisystem injury, the physician must also
consider head, neck, and intra-abdominal injuries when evaluating a child with
chest trauma. An overview of the approach to the child with blunt thoracic trauma
is shown in Figure 115.1 .

KEY POINTS