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


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


Tracheobronchial injuries are difficult to diagnose in children, and may
be indicated by the presence of subcutaneous air,
pneumomediastinum, or persistent air leak following tube thoracostomy
for pneumothorax.
In patients with suspected tracheal injury, endotracheal intubation
should be performed under bronchoscopic guidance in the operating
room when possible, to avoid converting a partial tracheal injury to a full
tear.
Symptoms of esophageal injury will depend on the region that
perforates, and symptoms may therefore refer to the neck, chest, back,
or abdomen. Delay in diagnosis has a significant impact on morbidity
and mortality.
While the finding of abdominal contents in the chest on radiograph is
specific for diaphragmatic rupture, it is insensitive, and this injury must
be considered any time there is significant blunt force to the abdomen
or penetrating injury to the chest.
The findings of traumatic asphyxia are dramatic, but patients who

survive the initial injury are most at risk from associated intra-abdominal
and intrathoracic injuries.

Tracheobronchial Injuries
Injury to the tracheobronchial tree in children occurs rarely, with an incidence of
less than 1% of injured children. This injury typically results from a high-energy
mechanism or a focused direct blow. Major vessels or pulmonary parenchyma are
more likely to be injured in penetrating trauma than the tracheobronchial tree.
Cervical tracheal rupture may be caused by a direct blow to the trachea or violent
flexion and extension of the patient’s head. This whiplash effect can cause a tear
between two cartilaginous rings. Lower tracheobronchial injury usually occurs
from a sudden increase in intrabronchial pressure. Because the child’s chest wall
is elastic, the trachea and main bronchi can be compressed between the chest wall
and the vertebral spine. Compression of the chest against a closed glottis can
cause a sudden increase in intrabronchial pressure, resulting in a tracheobronchial
tear. Shear forces, traction, and crushing the airway between the chest and
vertebral column may also cause a tracheobronchial injury. Approximately 80%
of tracheobronchial injuries occur on the posterior wall of the airway within 2 cm
of the carina.


The diagnosis of tracheobronchial injury may be difficult in the pediatric
population. The mechanism of injury (e.g., fall, crush, direct blow) provides an
important clue. Symptoms such as chest pain and dyspnea are common but
nonspecific. Clinical signs include cyanosis, hemoptysis, tachypnea, and
subcutaneous emphysema (cervical, mediastinal, or both). Pneumomediastinum
and cervical subcutaneous emphysema are seen commonly in airway rupture. If a
pneumothorax is present with these findings, a bronchial rupture should be
suspected. A continued air leak after insertion of a thoracostomy tube should alert
the physician to the possibility of a tracheobronchial disruption. Because of

anatomic differences, ruptures of the bronchi occur on the right side more
frequently than the left. In the absence of a pneumothorax, tracheal or esophageal
rupture should be suspected if a pneumomediastinum or cervical emphysema is
present. However, in most patients with asymptomatic pneumomediastinum, no
source is identified on evaluation.
The treatment includes initial airway stabilization and bronchoscopic
evaluation of the airway. Numerous case reports describe partial tracheal tears
becoming complete after endotracheal intubation. Therefore, if the airway is
stable and a tear is known or strongly suspected, oral tracheal intubation should
be performed in the operating room under bronchoscopic guidance. This prevents
further trauma to the airway, and if a complication arises, emergency surgical
access to the airway is readily available. If the airway is unstable and emergent
endotracheal intubation needs to be performed, backup surgical approaches
should be prepared. Emergent recruitment of a trauma or thoracic surgeon to
assist if tracheal disruption worsens can be lifesaving. An advantage of early
bronchoscopy is exact identification and location of the lesion. The best surgical
results are achieved when operative exploration is performed early ( Table 115.1
). In the stable patient, CT scan of the chest can also help confirm the diagnosis
and identify other injuries.

ESOPHAGEAL INJURIES
Esophageal injury is rare in children, and presents a diagnostic challenge when it
does occur. Timely and accurate diagnosis of an esophageal injury is paramount.
The complications of delayed diagnosis include mediastinal sepsis and death. The
most common cause for esophageal perforation in the pediatric population is
iatrogenic, followed by penetrating trauma (gunshot and stab wounds).
Esophageal perforation can occur in blunt trauma if there is a significant amount
of chest or pharyngeal compression. The cervical and thoracic regions are more