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from the heart, hilum, or lung. Catheters can also be placed directly into the right
atrium, helping with fluid resuscitation, and the thoracic aorta can be compressed,
improving circulation to the brain and heart.
While pediatric data on emergency thoracotomy are limited, reports suggest it
is more likely to be successful in penetrating than blunt trauma and in patients
who are not bradycardic or hypotensive. Current recommendations are that
emergency thoracotomy may be appropriate in patients who had vital signs in the
field but cardiac arrest on transport or in the ED, or patients who remain
hemodynamically unstable despite appropriate resuscitation after thoracic trauma,
if a thoracic or trauma surgeon is available within approximately 45 minutes.
Lifesaving interventions such as airway management, fluid resuscitation, and
pericardiocentesis should not be delayed while waiting for emergency
thoracotomy to be performed. The pediatric patient with vital signs, but not
responding to initial treatment such as tube thoracostomy and pericardiocentesis,
is a candidate for thoracotomy in the operating room, rather than the ED.

OTHER INTRATHORACIC INJURIES
Goals of Treatment
Diaphragmatic, esophageal, and tracheobronchial disruptions are rare and are
often overlooked in the initial evaluation of thoracic trauma. The CXR may
initially appear normal in 30% to 50% of diaphragmatic hernias. When abnormal,
the CXR may show a bowel gas pattern in the thoracic space, a displaced
nasogastric tube, or an elevated hemidiaphragm, more common on the left than
the right. The patient may complain of chest pain or difficulty breathing. The
examination may be normal or show decreased breath sounds, respiratory
distress, or a scaphoid abdomen. Surgical exploration is indicated in all suspected
cases because a diaphragmatic hernia does not improve without surgical
correction.
Patients with esophageal and tracheobronchial disruptions may present with
pneumomediastinum, subcutaneous emphysema, a continuous air leak following
tube thoracostomy, or, for those patients with esophageal disruption, fever and

gastric contents from the chest tube. Bronchoscopy and/or esophagoscopy are
indicated in suspected cases.
CLINICAL PEARLS AND PITFALLS