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in adults. Hemothorax secondary to an injury of the great vessels usually results
in death at the scene. Hemothorax from injury to smaller vessels and
pneumothorax have low mortality rates.

Goals of Treatment
Immediate recognition and stabilization of airway, breathing, and circulation is
crucial to management of pneumothoraces and hemothoraces. Opening and then
securing the airway with endotracheal intubation is the first step for a child with
severe respiratory distress, inadequate oxygenation or ventilation, or depressed
mental status after trauma. Breathing may be supported via mechanical
ventilation and evacuation of intrapleural air and blood. Circulation may become
impaired during tension physiology via obstruction of venous return, and
evacuation of the pleura via needle or tube thoracostomy is immediately
necessary. Circulation may also be affected by blood loss into the thorax
necessitating volume replacement with appropriate IVF and possible blood
transfusion.
For the stable patient with pneumo- or hemothorax, the focus is on careful
evaluation and treatment to prevent deterioration. Chest radiograph (CXR) and
ultrasound (US) may be helpful to identify the extent of the injury and the need
for intervention. Depending on the clinical progression, treatment may involve
observation, tube thoracostomy, or surgical intervention.

Clinical Considerations
Clinical Recognition
Pneumothorax or hemothorax should be suspected in any child with a history of
thoracic trauma who presents with chest pain, shortness of breath, respiratory
distress, hypoxia, or evidence of shock. Physical examination alone may be
sufficient to make the diagnosis in patients with a large hemothorax or
pneumothorax or severe complications such as tension physiology, but smaller
lesions may be missed by examination alone. All patients with a mechanism for a
thoracic injury should undergo prompt radiologic evaluation with CXR, as an

initial normal physical examination may be misleading. Where available, bedside
US can be used to augment the initial physical examination as it may facilitate
identification of even small amounts of air or blood in the pleural space.
Triage Considerations
Children with traumatic pneumothorax or hemothorax require immediate
evaluation utilizing Advanced Trauma Life Support (ATLS) protocols and
activation of the appropriate local trauma response. In planning for a trauma