FIGURE 115.3 A 5-year-old girl fell off and was then kicked in the chest by a horse. Upon
arrival of the life-flight team, the patient was found to be in both respiratory and cardiovascular
distress. Chest radiograph demonstrated a left-sided tension pneumothorax. The patient was
intubated, and a chest tube was placed before the patient was transported. After the intubation
and chest tube insertion, both the patient’s respiratory and cardiovascular status improved.

Reported sensitivity of the E-FAST examination in children is lower than that
noted in adults. In addition, children are less likely to undergo operative repair
even when free fluid in the abdomen is identified, therefore the role for FAST
testing is different in children than adults. Nonetheless, with thoracic trauma,
identification of air or blood in the pleural space on avoid confusion may rapidly
influence the decision for tube thoracostomy in children with respiratory or
hemodynamic compromise.

Management
Needle Decompression


Initial treatment for pneumothorax may consist of observation alone, placement
of a chest tube, or needle thoracentesis. Tension pneumothorax, however, should
always be treated with immediate needle decompression. This is performed by
insertion of a large-bore intravenous (IV) catheter in the midclavicular second
intercostal space of the ipsilateral side, or in the fourth or fifth intercostal space in
the anterior axillary line. If there is a tension pneumothorax, an immediate release
of air should be noted. Evacuation can be facilitated by attaching the catheter to a
two-way stopcock and 60-cc syringe, allowing air to be continuously pulled from
the pleural space although the placement of the catheter alone should temporarily
resolve the tension physiology until tube thoracostomy can be performed. When
using a stopcock and syringe, care must be taken to avoid leaving the stopcock in
place but closed after evacuation of air to prevent recurrence of pleural air and
potentially tension physiology.

Chest Tube
Tube thoracostomy is indicated in the symptomatic patient with pneumothorax or
those requiring air transport. Management of asymptomatic pneumothoraces
identified on CT but not visible on plain radiograph is controversial, but tube
thoracostomy does not appear to be required, even in patients undergoing positive
pressure ventilation.
Tube thoracostomy should be done in the midaxillary line at the level of the
fifth intercostal space (nipple level). If the pneumothorax is not relieved and a
significant air leak continues after chest tube placement, a tracheobronchial
rupture must be considered. Evidence suggests that for a simple pneumothorax,
placement of a pigtail catheter instead of a chest tube has similar efficacy while
causing less pain to the patient. While data in children are lacking, pigtail catheter
placement is often preferred to surgical tube thoracostomy for management of
pneumothoraces due to less need for procedural sedation and postprocedural pain
medication.
Tube thoracostomy, and not pigtail catheter placement, is the treatment of
choice in patients with a hemothorax in order to evacuate blood from the pleural
cavity, reexpand the lung, and prevent or treat any mediastinal shift. Many
hemothoraces may actually represent hemopneumothoraces. As with a
pneumothorax, the chest tube is placed in the midaxillary line at the level of the
fifth intercostal space (nipple level). Patients should be typed and crossed for
packed red blood cells and adequately volume resuscitated, preferably with two
large IV lines in place. For larger hemothoraces, donor blood should be at the
patient’s bedside prior to tube thoracostomy if time permits. After placement of a


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



Pulmonary contusion is the most common intrathoracic injury in
children.
While many contusions cause only mild symptoms such as chest pain,
more severe injuries can lead to hypoxemia and respiratory failure.
Pulmonary contusions may not show up on CXR for 4 to 6 hours after
the injury, and in some cases may never be identified on plain films.
Given the force necessary to cause a pulmonary contusion, a high
index of suspicion for other associated injuries is required.

Current Evidence
Pulmonary contusion is the most common thoracic injury in children. Pulmonary
contusion occurs when a blunt force is applied to the lung parenchyma, though
the injury can also be seen in penetrating trauma. The pediatric thoracic cage
provides less protection from blunt force impact compared to adults, secondary to
greater cartilage content and the greater elasticity of the bones. Therefore,
external kinetic energy applied to the thorax is transferred more readily through
the chest wall to the underlying organs. Thus, a pediatric patient is more likely
than an adult to have an internal injury such as a lung contusion without external
evidence of trauma (e.g., rib fracture, laceration, bruising).
As in any contusion or bruise, the capillary network becomes damaged, leaking
fluid into the surrounding tissues. A ventilation:perfusion mismatch will occur
because of the extravasation of fluid into injured lung parenchyma, interfering
with oxygenation. As the edema and swelling worsen, the patient’s respiratory
status will deteriorate if the contusion is large.

Clinical Considerations
Clinical Recognition
Pulmonary contusion should be suspected in any child with blunt thoracic trauma
who presents with chest pain, difficulty breathing, or unexplained hypoxia. The
contusion may be visualized on radiography or inferred from the absence of

another explanation for these symptoms (such as pneumothorax). Due to the
pliable nature of the pediatric chest wall, pulmonary contusions can often be seen
in the absence of rib fracture. When present, however, rib fractures as well as
chest wall ecchymosis should further raise suspicion for underlying parenchymal
injury.
Triage