in adults. Hemothorax secondary to an injury of the great vessels usually results
in death at the scene. Hemothorax from injury to smaller vessels and
pneumothorax have low mortality rates.

Goals of Treatment
Immediate recognition and stabilization of airway, breathing, and circulation is
crucial to management of pneumothoraces and hemothoraces. Opening and then
securing the airway with endotracheal intubation is the first step for a child with
severe respiratory distress, inadequate oxygenation or ventilation, or depressed
mental status after trauma. Breathing may be supported via mechanical
ventilation and evacuation of intrapleural air and blood. Circulation may become
impaired during tension physiology via obstruction of venous return, and
evacuation of the pleura via needle or tube thoracostomy is immediately
necessary. Circulation may also be affected by blood loss into the thorax
necessitating volume replacement with appropriate IVF and possible blood
transfusion.
For the stable patient with pneumo- or hemothorax, the focus is on careful
evaluation and treatment to prevent deterioration. Chest radiograph (CXR) and
ultrasound (US) may be helpful to identify the extent of the injury and the need
for intervention. Depending on the clinical progression, treatment may involve
observation, tube thoracostomy, or surgical intervention.

Clinical Considerations
Clinical Recognition
Pneumothorax or hemothorax should be suspected in any child with a history of
thoracic trauma who presents with chest pain, shortness of breath, respiratory
distress, hypoxia, or evidence of shock. Physical examination alone may be
sufficient to make the diagnosis in patients with a large hemothorax or
pneumothorax or severe complications such as tension physiology, but smaller
lesions may be missed by examination alone. All patients with a mechanism for a
thoracic injury should undergo prompt radiologic evaluation with CXR, as an

initial normal physical examination may be misleading. Where available, bedside
US can be used to augment the initial physical examination as it may facilitate
identification of even small amounts of air or blood in the pleural space.
Triage Considerations
Children with traumatic pneumothorax or hemothorax require immediate
evaluation utilizing Advanced Trauma Life Support (ATLS) protocols and
activation of the appropriate local trauma response. In planning for a trauma


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


lung, but it also compresses the contralateral lung ( Fig. 115.2 ). These patients
may present in severe respiratory distress with decreased breath sounds on the
side of the pneumothorax. There is also a shift of the mediastinal structures to the
contralateral side. Two-thirds of the blood supply to the body is returned to the
heart via the inferior vena cava. Because the inferior vena cava is relatively fixed
in place as it passes through the diaphragm and cannot shift as much as the
superior vena cava, venous return to the heart is reduced.

FIGURE 115.2 Tension pneumothorax with a mediastinal shift.

Some patients with a pneumothorax or hemothorax demonstrate tension
physiology: tachycardia and peripheral vasoconstriction. If left untreated, this will
progress to shock. Initial treatment for tension physiology consists of needle

decompression. An immediate release of air should be noted with tension
pneumothorax and the patient’s hemodynamic status should improve. The needle
decompression is only a temporizing measure and must be followed by tube
thoracostomy.
Open Pneumothorax
An open pneumothorax is the result of penetrating trauma. There is a direct
connection between the pleural space and the atmosphere, impeding ventilation.
As in a bronchial tear or lung parenchymal injury, air may enter but not leave the
pleural space, creating a ball-valve effect. Initial treatment includes placement of


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.