Pediatric emergency medicine trisk 3696 3696

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