Pediatric emergency medicine trisk 3703 3703

chest tube, blood should be slowly evacuated from the pleural space. Blood
within the pleural cavity may tamponade a significant bleeding source within the
chest and evacuating that blood may cause new bleeding to occur. Patients can
exsanguinate rapidly, which is why IV access, adequate volume resuscitation, and
blood available for transfusion should be priorities. Thoracostomy drainage needs
to be closely monitored. Large ongoing blood loss from a chest tube should be
collected in a system that allows autotransfusion.
Thoracotomy
Thoracotomy is indicated for bleeding that continues at a rate of greater than 1 to
2 mL/kg/hr, inability to expand the lung, or retained blood within the pleural
cavity. Failure to adequately drain a hemothorax may lead to restrictive lung
disease from a fibrothorax or an empyema from the clotted material becoming
infected.

Disposition
All patients with a traumatic pneumothorax or hemothorax require admission to
the hospital. If the pneumothorax is small and the patient is asymptomatic,
hospital observation and passive administration of oxygen via a nonrebreather
mask is all that is necessary. A small pneumothorax is classically described as
being less than 15% of the hemithorax, although it is common to underestimate
the size of a pneumothorax using plain films. An asymptomatic patient may
rapidly become symptomatic if a small, simple pneumothorax progresses to a
large or tension pneumothorax; therefore, even asymptomatic patients with a
traumatic pneumothorax should be admitted to the hospital for observation.
Patients with chest tubes should be hospitalized on a unit that is capable of
monitoring and troubleshooting the tube and the collection device.
An unstable airway, respiratory distress, severe hypoxia, ongoing blood loss,
and presence of other severe injuries are among the indications for admission to
an intensive care unit.

PULMONARY CONTUSIONS

CLINICAL PEARLS AND PITFALLS