Pediatric emergency medicine trisk 3700 3700

an occlusive dressing at the wound site. This is best done when the patient is in
full expiration. A chest tube should be placed immediately to prevent
development of a tension pneumothorax. The chest tube should be inserted at a
site different than the open wound. Larger open chest wounds may need surgical
closure.

Diagnostic Testing
Chest Radiograph
A CXR remains the most widely used test for the diagnosis of hemothorax and
pneumothorax. Both conditions are better visualized in the upright position than
supine. Plain radiographic signs of a pneumothorax may include identification of
the pleural line, a hyperlucent hemithorax, pleural air at the lung base, and/or an
unusually well-defined heart and mediastinal outline due to pleural air rising
anteriorly. A tension pneumothorax is indicated by the presence of midline shift
to the contralateral side of the pneumothorax ( Fig. 115.3 ). Smaller
pneumothoraces may be better visualized by positioning the patient in the lateral
decubitus position with the concerning side up. Expiratory CXRs do not add
significantly to the evaluation. Hemothorax on CXR may appear as blunting of
the costophrenic angle, haziness or opacification of the hemithorax, or a visible
air–fluid level.
Bedside Ultrasound
Bedside US has become part of the standard assessment of trauma patients due to
its ability to rapidly detect injuries and inform management strategies. The major
finding of pneumothorax is absence of lung sliding, while hemothorax is
determined by the presence of fluid in the pleural space. Studies in adults have
shown the extended focused assessment with sonography for trauma (E-FAST)
examination to be more sensitive in the detection of pneumothorax than supine
radiographs with a sensitivity between 50% and 80% and specificity of 95% to
100% when compared to chest CT. In the multiply injured or unstable patient, US
may be particularly valuable in prioritizing further evaluation and interventions,
particularly in adult patients.