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response, preparations should be made for both needle aspiration of pleural air
and placement of a chest tube, so that these procedures can be performed without
delay if indicated by the patient’s clinical condition or diagnostic workup.
Clinical Assessment
The child with suspected pneumothorax or hemothorax should undergo a
thorough primary survey, looking for signs of compromised airway, breathing, or
circulation. Careful attention to vital signs, particularly tachycardia, tachypnea,
and hypoxemia, may lead to discovery of impaired physiology not otherwise
detected by physical examination. It is important to recognize that due to
children’s excellent vascular compensation abilities, hypotension is a late finding
in pediatric shock and a normal blood pressure therefore does not rule out
circulatory compromise.
Some patients with a pneumothorax may be asymptomatic. Others may be
tachypneic, complain of pleuritic chest pain, or be in severe respiratory distress.
Physical examination may be normal or may reveal diminished or absent breath
sounds, crepitus, or hyperresonance to percussion on the side of the
pneumothorax. If a tension pneumothorax develops, findings may include
tracheal deviation to the contralateral side and distended neck veins from
impaired venous return to the heart through the deviated superior vena cava.
Some of these physical findings may be difficult to discern in a fully immobilized
child in a noisy resuscitation room.
Patients with hemothorax may present in respiratory distress or profound shock
secondary to obstruction of venous return or blood loss. Decreased breath sounds
are noted on the affected side, and there may be tracheal or mediastinal deviation.
Thirty percent to 40% of the patient’s blood volume may be rapidly lost in the
pleural cavity with major vessel lacerations. Bleeding from the intercostal or
internal mammary arteries usually stops as systemic blood pressure falls and
reexpansion of the lung may provide some tamponade effect.
Tension Pneumothorax
A tension pneumothorax is the most common complicated intrapleural injury.
Tension pneumothorax develops in up to 20% of children after simple

pneumothorax. A tension pneumothorax occurs when there is progressive
accumulation of air within the pleural cavity. A laceration to the chest wall,
pulmonary parenchyma, or tracheobronchial tree may function as a one-way
valve, allowing air to enter but not leave the pleural space. The progressive
accumulation of air within the pleural cavity not only collapses the ipsilateral