Pediatric emergency medicine trisk 3721 3721

Penetrating thoracic trauma in children is less common than blunt trauma,
accounting for 20% of pediatric thoracic injuries in one study. The most common
mechanisms of injury were gunshot wounds and stab wounds. Unlike blunt
thoracic trauma, where observation and supportive therapies are most common,
penetrating thoracic trauma often requires invasive interventions. The most
common penetrating thoracic injuries are hemothorax and pneumothorax, almost
always requiring tube thoracostomy. More children with penetrating thoracic
injury will require operative intervention because of the close proximity of the
vital organs in the thoracic cavity in children, as compared with adults.
Evaluation and treatment includes airway stabilization, fluid resuscitation, and
management of the chest wound. Radiopaque markers (such as paper clips) may
be placed by the entry and exit sites to help determine the course of the missile.
Pericardial tamponade should be considered and immediately treated in the
unstable patient. In the stable patient, transesophageal or transthoracic
echocardiogram is helpful in evaluating the heart and determining if there is fluid
within the pericardial sac. Diaphragmatic lacerations are difficult to diagnose and
may require exploratory laparotomy, thoracoscopy, or laparoscopy for diagnosis
and treatment.
CLINICAL PEARLS AND PITFALLS
Penetrating trauma remains uncommon in children, but confers a high
mortality risk.
Presence of hemothorax, pneumothorax, or pericardial tamponade
necessitates emergent tube thoracostomy or pericardiocentesis,
respectively.
Many patients will also have involvement of the abdomen, which
requires thorough evaluation.
Significant or fluid-resistant hypotension indicates the need for
emergent thoracotomy.

Emergency Thoracotomy
Emergency thoracotomy is the most aggressive resuscitative measure for patients

with thoracic trauma. With the advancement of transport systems and
regionalization of trauma centers, patients who previously would have died at the
scene are now surviving to arrival to trauma centers for evaluation and treatment.
Emergency thoracotomy allows the physician to evaluate and evacuate the
pericardial sac, perform open cardiac massage, and temporarily control bleeding