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Key Points

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  1. The initial approach to thoracic trauma is no different from that employed for any child who is seriously injured. Priorities includes securing the airway, maximizing breathing, and ensuring that circulation is adequate.

  2. Mortality from blunt trauma is usually related to associated injuries.

  3. Emergency department (ED) thoracotomy should be performed solely for patients having suffered a penetrating injury with signs of life either at the scene or on arrival.

  4. The most important principle in managing children with rib fractures is adequate control of pain.

  5. The majority of injuries to the lung and pleura are successfully managed with tube thoracostomy and rarely require thoracotomy.

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Epidemiology

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Thoracic injuries occur in 4.4% of children with serious injuries, making them relatively uncommon among children admitted to a major trauma center. The most common injuries are pulmonary contusions, pneumo- and hemothorax, and rib fractures, representing 48%, 39%, and 32% of chest injuries, respectively.

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Blunt trauma is by far the most common mechanism of injury; motor vehicle crashes and intentional injuries are the most common etiologies. Penetrating chest injuries, mostly caused by firearms, had increased through the early 90s, although more recent data suggest that this trend may be reversing.

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Reported mortality rates associated with thoracic injuries vary from 7% to 26%. In blunt trauma, isolated thoracic injuries are only associated with a 5% mortality. However, mortality increases to 25% when head or abdominal injuries are also present, and increases to as much as 40% when both head and abdominal injuries are present. In our experience, approximately 20% of children with a thoracic injury will require a tube thorocostomy. Life-threatening isolated chest injuries are rare, and immediate thoracotomy is necessary in only 3% to 6% of patients.

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Diagnosis

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Although the physical examination may reveal important markers of injury, alone it is inexact in definitively establishing the presence or absence of thoracic injuries. Concerning physical findings, examination should prompt further diagnostic studies. The initial assessment including physical examination and chest x-ray should be performed in a timely manner in order to promptly identify patients with life-threatening injuries such as tension pneumothorax, tracheobronchial injuries, massive hemothorax, and aortic injuries.

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Physical examination should start with visual inspection for symmetric chest wall rising and evidence of abrasions, hematoma, or open wounds. The neck should also be inspected for signs of tracheal deviation and venous jugular distension. The chest wall is then palpated to identify bony abnormalities, hematomas, subcutaneous epmphysema, and areas of tenderness. Finally, the chest is auscultated keeping in mind that breath sounds in a small child can be easily transmitted across the mediastinum resulting in the delayed recognition of hemo- or pneumothorax.

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In patients sustaining penetrating injuries, the chest should be carefully examined to identify all wounds. A cardiac injury is suggested by parasternal wounds and an associated intra-abdominal injury is suggested by penetrating ...

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