Figure 29-1. Broselow pediatric emergency resuscitation tape.

2 As in adults, the primary survey should focus on the identification of acute life-threatening injuries. Attention to the airway, breathing, and circulation (ABCs) supersedes all other interventions in the initial resuscitation phase. All centers that care for children should have sequestered resuscitation equipment designed for children, that is, endotracheal tubes (ETTs), laryngoscopes, catheters, and passive warming lamps. Room temperature should be kept warm to limit insensible heat losses in small children. The Broselow Pediatric Emergency Tape aides in estimating the weight of the child by measuring his or her length. A color-coded bar on the tape measures the length of the child and indicates the appropriate equipment sizes and medication doses to perform emergency resuscitation on the child. Designated resuscitation equipment is contained in corresponding, color coded equipment pouches or drawers (Fig. 29-1).

Pediatric vital signs vary by age (Table 29-1). Children are able to maintain normal blood pressures until late hemorrhagic shock (>30% blood loss), and, therefore, subtle changes in heart rate and respiratory rate must be noted. As a general rule, the lower limit of acceptable systolic blood pressure = Age × 2) + 70 mm Hg. For newborns, acceptable systolic blood pressure is 60 mm Hg or greater.

Airway control (“A”) is the first priority. Cardiac arrest in a child is most often of respiratory etiology, and an injured child who is obtunded, unresponsive, or combative may need to be intubated. An uncooperative child who needs radiologic imaging may also need to be intubated. Intubation must be performed with the jaw thrust technique and in-line cervical stabilization. Keep in mind these key anatomic differences for intubation in children: larger tongue, more narrow and anterior glottis, and shorter trachea. You may find that a straight Miller blade is easier than the curved Mac blade because the epiglottis is floppy (less cartilaginous). The appropriate size of ETT can be estimated by the size of pinkie finger (or the formula = [age + 16]/4). The Broselow Pediatric Emergency Resuscitation Tape is also a useful tool to estimate ETT (and other device) size and medication doses, given a child’s height or weight. Use an uncuffed ETT in a young child (<8 years of age or approximately 60 lb), because the subglottic trachea is narrow and provides a sufficient seal. However, cuffed ETT may be used (except in newborns), if appropriate cuff pressures are used. Rapid sequence intubation is similar to adults, including preoxygenation with 100% FiO₂, medication administration, cricoid pressure, cervical spine stabilization, laryngoscopy, and advancement of tube to an appropriate distance beyond the cords. Confirm exhaled CO₂ and secure the tube. In the rare event of acute airway obstruction, needle cricothyroidotomy with a 14 g catheter is preferential to open cricothyroidotomy because of the increased incidence of subglottic stenosis.

After securing the airway, assess the child’s breathing (“B”). If there is difficulty with respiration, assist the ventilation and assess for potential life-threatening thoracic injuries: pneumothorax (open chest wound or tension pneumothorax), hemothorax, flail chest/pulmonary contusions, and rib fractures with splinted breathing. The mediastinum of a child is very compliant and can lead to rapid decline from a tension pneumothorax. These life-threatening injuries must be rapidly identified and treated. Children are diaphragmatic breathers and, therefore, gastric distension can be an unrecognized contributor to respiratory distress, especially in the young child who is distended from swallowing air while crying. If there are concerns for abdominal distension, a nasogastric tube should be placed to decompress the stomach. Use an orogastric tube in babies, who are obligate nose breathers.

Hemorrhage is the most common etiology of Circulatory compromise (“C”) in trauma, but do not overlook obstructive etiologies (cardiac tamponade and tension pneumothorax) and distributive etiologies (neurogenic shock). Assessment of volume status and shock is difficult in the child. Children have impressive physiologic reserve and can maintain systolic blood pressure until late-stage hypovolemic shock (>30% blood loss). Tachycardia, tachypnea, altered level of consciousness, and poor peripheral perfusion (mottled cool extremities, weak thready pulses, narrowed pulse pressure, delayed capillary refill) are early but subtle signs of blood loss. Establishing vascular access in an injured child is a priority and can be challenging. Peripheral intravenous lines are ideal, but when they cannot be obtained, intraosseous lines are quick, reliable, and allow high-volume infusion of any fluid (crystalloid, blood products, and even medications, including pressors). An intraosseous line is placed in the anteromedial tibia, 2- to 3-cm distal to the tibial tuberosity after a quick skin preparation for sterility (Fig. 29-2). Avoid wounds, fractures, or infected areas. They should ideally be placed with a single attempt because multiple holes can lead to leakage of infusion fluids and resultant compartment syndrome. If contraindicated, definitive intravenous (IV) access can be obtained with a central line in the femoral vein or a peripheral vein cut down (i.e., saphenous vein).

Initial fluid resuscitation is indicated when there are signs of hypovolemic shock. Initial bolus consists of 20 mL/kg of warmed normal saline or lactated Ringer’s solution. This may be repeated if there is no response or only a transient response. All subsequent volume resuscitation should be performed with blood products (10 mL/kg = “1 unit”) (Table 29-2). If there is no time for cross-matched, type-specific blood, “O-negative” blood is indicated. Massive transfusion protocols may be initiated at this time if indicated and should include hemostatic resuscitation with packed red blood cells, fresh frozen plasma, and platelets, targeting high plasma-to-red blood cell and platelet-to-red blood cell ratios.¹⁸ In the most recent advanced trauma life support protocols, this has become known as “damage control resuscitation,”¹⁹ espousing permissive hypotension, minimizing crystalloid resuscitation, and promoting early blood product administration for the treatment of the lethal triad (acidosis, coagulopathy, and hypothermia) of severe uncontrolled hemorrhage. There is, however, no evidence-based support for permissive hypotension strategies in pediatric trauma patients. As in adults, ongoing hemodynamic instability from blood loss in a child must be controlled expeditiously. Sources of bleeding can be thought of in terms of body compartments: including the chest, peritoneal cavity, retroperitoneum/pelvis, femur fracture/thigh compartment, and external injury (especially the scalp). In an infant, prior to suture closure of the skull, intracranial hemorrhage may produce hemodynamic instability. Once resuscitated, maintenance fluid requirements (Table 29-2) can be estimated using the “4-2-1” rule and should be administered as D5 1/2NS (or D10 1/2NS for neonates).

A brief neurologic assessment is part of the primary survey (“D” for disability). Head injury accounts for the highest degree of morbidity and mortality in children and is the principle determinant of outcome after trauma. However, children have the potential for more frequent and fuller recovery from even serious head injury, when compared to similar injuries in adults.²⁰ Therefore, careful attention to preventing secondary injury and maximizing tissue perfusion to the brain can greatly improve outcome. These secondary insults include ischemia, hypoxia, hypotension, hyperthermia, hypercapnia, acidosis, and increased intracranial pressure (ICP). The Glasgow Coma Scale (GCS) is modified in young children who are preverbal to measure neurologic function and prognosis. The motor response scale tends to provide the most reliable assessment of function in a preverbal or intubated child (Table 29-3).

In preparation for the secondary survey, the child must be Exposed (“E”) completely for a complete head-to-toe physical examination. Keep in mind that they also have a larger body surface area ratio and, therefore, lose heat and water quickly and can become hypothermic. Use warm fluids, bare huggers, warming lights, and warm ambient room temperature to prevent heat loss in a child and the secondary coagulopathy that is associated with hypothermia.

Only after the primary assessment is complete, and ABCs are secured, do we move on to the full secondary survey. In reality, with a team approach to management of the pediatric trauma patient, much of the supportive care happens concurrently with the primary and secondary surveys, including placement of intravenous lines, drawing laboratories, applying monitors and oxygen, and obtaining ancillary diagnostic tests. Adjunct diagnostic modalities and imaging may be used to provide additional information in the evaluation of a pediatric trauma patient. Although diagnostic peritoneal aspiration has been traditionally used to evaluate intra-abdominal injuries in the unstable patient, it has no role in the pediatric population where solid organ injuries are unlikely to require surgery. Focused assessment with sonography in trauma (FAST) examination has significant advantages over more invasive diagnostic maneuvers: the FAST examination can be performed quickly and exposes the patient to no potential harm from delay or ionizing radiation. However, children with intra-abdominal injuries are more frequently managed nonoperatively, and thus the need for rapid decision making regarding operative management is less common. Children also have a relatively higher incidence of solid organ injury without free fluid, and consequently, a negative FAST examination may not obviate the need for an abdominal computed tomography (CT) when there is a clinical suspicion of significant injury. The FAST examination should not be relied on as a stand-alone screening tool in the pediatric population.^21,22 Findings from chest radiography, anteroposterior pelvis radiography, and the FAST examination, along with the primary and secondary surveys, guide decisions regarding further radiographic examination, including CT or plain radiography.

In addition to a full physical examination, a brief history is essential and is often provided by emergency medical services (EMS) personnel or the parents. An “AMPLE” history helps the provider focus on essential information such as Allergies, Medications, Past medical history, Last meal, and Events surrounding the traumatic incident. Blunt trauma is the most common mechanism after which children present for evaluation. Children are more prone to multisystem trauma due to their small body size and more compliant body (less protective bones, muscle, and torso fat). Blunt trauma can result in injury patterns that resemble penetrating injuries, without significant external signs of trauma. Careful attention to a bruise on the abdominal wall resulting from a bicycle handlebar should lead to a more thorough investigation of the abdomen. A lap belt mark across the abdomen may raise concerns of lumbar spine fracture (Chance fracture), with an associated risk of small bowel injury. A history of significant hemorrhage at the scene may instigate a more thorough investigation of the vessels in the proximity of injury in an otherwise hemodynamically stable patient who has no hard signs of vascular injury. Therefore, a thorough history, mechanism of injury, and focused examination of the entire child is mandated so that signs of forceful impact can be elucidated.

MANAGEMENT OF SPECIFIC INJURIES

Traumatic Brain Injury

Traumatic brain injury is the leading cause of death and disability in children,^20,23,24 and is an important determinant of outcome. Physical abuse such as shaken baby syndrome is the most common cause of head injury in children younger than 2 years, and blunt head trauma from motor vehicle accidents, falls, or bicycle/pedestrian accidents are responsible for most injuries in children older than 2 years. Injury prevention strategies are necessary for improving outcomes of the primary TBI. However, reduction of secondary injury patterns is critical in children, who have impressive physiologic reserve and potential for rehabilitation after brain injury. Focus must be on preserving cerebral oxygenation and perfusion and mitigate toxic exposures to minimize secondary brain injury. This includes treating or preventing hypotension, hypoxia, hyper or hypocarbia, hyperoxia with generation of ischemia reperfusion free-radicals, hyperthermia, seizures, and intracranial hypertension.

Mild Traumatic Brain Injury

Children with minor head trauma can present the greatest challenge to emergency department personnel. Eastern Association for the Surgery of Trauma (EAST) guidelines define mild traumatic brain injury (MTBI) to be interchangeable with the term “Concussion,” involving a blunt force mechanism with alteration in brain function (i.e., GCS score of 13 to 15) but by definition must have a normal head CT if performed.²⁵ Significant brain injuries need to be identified early and treatment instituted rapidly. CT scans provide the most accurate and expeditious means of diagnosis but expose many pediatric patients to unnecessary radiation. Evidence-based clinical decision tools have helped identify the population of children who benefit most from radiologic evaluation. The TBI study group for PECARN (Pediatric Emergency Care Applied Research Network) has developed tools for assessment of children after blunt head injury.^25–30 The “PECARN Rules,”²⁶ (Algorithm 29-1) identify children at very low risk (<0.05%) of having clinically important TBI requiring intervention. These patients can avoid CT and be discharged safely with appropriate instructions. Children with abnormal GCS score (GCS score of ≤14) or evidence of skull fracture are at the highest risk for clinically important injury and should be evaluated emergently by CT scan. If there is a history of loss of consciousness, severe injury mechanism, abnormal behavior to the parent or nonfrontal scalp location (<2 years), or vomiting and severe headache (≥2 years), then further observation or CT should be offered as reasonable management options. Subsequent analyses also identified children with only isolated loss of consciousness (and no other PECARN predictors) to be at very low risk for clinically important TBI.²⁷ Children with MTBI (GCS score of 14 to 15) who underwent CT can be safely discharged home without further neurologic monitoring, if their head CT scan is normal.^25,28 Even those with an isolated skull fracture can be discharged home from the emergency department with strict discharge instructions and return precautions.^29,30,31,32 At this point, routine structural or functional imaging modalities such as magnetic resonance imaging, functional magnetic resonance imaging, or positron emission tomography for diagnosis or prognosis of MTBI are not supported.²⁵

Prognosis and outcome in MTBI, especially as it relates to “return to learn or return to play” after concussion, is still hotly debated. Most studies agree that patients with MTBI return to baseline within 3 months (majority within 10 to 14 days), but certainly symptom resolution can take longer. Lingering symptoms of headache, dizziness, fatigue, sleep disturbance, impairment in memory and concentration, irritability, anxiety, or depression are referred to as the “postconcussive syndrome,” which is not a well-understood entity.²⁵ Standardized tools exist, such as the Immediate Postconcussion Assessment and Cognitive Testing Battery (ImPACT), to aid clinicians in functional assessment of patients with MTBI.³³ The well-known NCAA Concussion Study from 2003 found that high-level athletes were more likely to sustain repeat concussions, which were associated with a longer recovery time,³⁴ and it has been increasingly recognized that repeat concussions can have permanent and sometimes devastating effects. In 2010, the American Academy of Pediatrics officially endorsed the International Conference on Concussion in Sport recommendations for a graduated “Return to Play” protocol (available online: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004129/table/T1/, last accessed April 5, 2016).^35,36 The CDC HEADS UP guidelines also incorporate these recommendations³⁷ and provide resources for schools, coaches, and primary care providers on returning to school and sports after a concussion. Data are lacking in the efficacy of these guidelines and their role in preventing recurrent concussions.³⁸

Moderate to Severe TBI

More serious head injury needs to be evaluated and treated expeditiously. The GCS (and modified GCS for infants) is a universal tool that can be used for rapid assessment of neurologic function and is based on verbal response, motor function, and eye opening. Moderate TBI is considered GCS score of 9 to 12 or 13 and severe TBI includes GCS score of ≤8, the definition of a coma. The goal of initial assessment and resuscitation in a severely brain injured patient is to minimize or prevent secondary brain injury. Attention to ABCs is critical, with maintenance of normotension and normoxia. Management of severe TBI in the pediatric intensive care unit is largely focused on management of elevated ICP and maintenance of cerebral perfusion pressure.³⁹ In 2003 and again in 2012, guidelines for the acute medical management of severe TBI in infants, children, and adolescents were published, which represented the first recommendations made specifically for pediatric patients (Tables 29-4 and 29-5).^40–43 These guidelines, composed mostly of class II or III evidence, included recommendations on management of intracranial hypertension, hypoxia/airway management, indications for ICP monitoring, thresholds for treatment and management of cerebral perfusion pressure, and hypotension. It also addressed therapies such as cerebrospinal fluid drainage, hyperosmolar therapies, hyperventilation, barbiturates, decompressive surgery, temperature control, corticosteroids, and supportive care such as sedatives/neuromuscular antagonists and nutrition, although the guidelines are mostly based on expert panel opinion rather than large clinical trials. Prehospital management focused on the benefit of pediatric trauma centers rather than adult trauma centers for children with severe TBI. Supplemental oxygen should be administered. There was no superiority of endotracheal intubation versus bag-mask ventilation in the prehospital setting, but if endotracheal intubation is to be undertaken, specialized training and the use of end-tidal CO₂ monitoring is encouraged. Hyperventilation with hypocarbia (pCO₂ <30 to 35) is to be avoided. There was class II support for ICP monitoring for children with GCS score of 8 or less; using an ICP threshold of 20 mm Hg and a cerebral perfusion pressure of 40 to 65 mm Hg; efficacy of hypertonic saline solutions in lowering ICP; and the role for decompressive surgery in the treatment of elevated ICP. From these guidelines, an algorithm for the management of acute intracranial hypertension was developed on the basis of the expert opinions of the committee (Algorithm 29-2), which has served as a template for clinical protocols for patient care and research. The 2012 guidelines changed a few of the recommendations (Table 29-5). Only hyperosmolar therapy was supported by two small studies (class II data); the remaining therapeutics could not be supported by the literature, including use of corticosteroids, immune-modulating diets, and induction of moderate hypothermia (“Cool Kids” trial).^44,45 Other topics with class III evidence were added including advanced neuromonitoring (using a brain–tissue oxygen partial pressure of 10 mm Hg), neuroimaging (avoiding routine repeat head CT unless neurologic deterioration), cerebrospinal fluid drainage, and the use of antiseizure prophylaxis (phenytoin prophylaxis) to reduce posttraumatic seizures. For a variety of other topics, including glycemic control, cerebrospinal fluid drainage, and analgesics/sedatives/neuromuscular blockade, definitive recommendations could not be made on the basis of the available literature. Overall, there is still a paucity of high-quality evidence to make specific treatment plans for children with severe TBI, but this allows for a wide variety of clinical approaches that are considered within the guidelines of pediatric care.

Spine Trauma

3 Cervical spine injuries (CSI) in blunt trauma pediatric patients occur in less than 2% of seriously injured children. Despite this low incidence, it is clear that many clinicians obtain radiographs in order to exclude CSI. The added benefit of routine imaging in the pediatric trauma evaluation is debatable. In recent years, concerns have been raised about the liberal use of plain films, CT scans, and magnetic resonance images in children with reference to imaging-related short- and long-term morbidity, resource consumption, and cost. The increased risk of fatal and nonfatal cancers associated with CT-related radiation has gained attention both by physicians and also by consumers. Both the U.S. Food and Drug Administration Center for Devices and Radiological Health (FDA) and the National Cancer Institute have published guidelines designed to limit unnecessary imaging in children. Although proponents of liberal imaging argue that a single missed CSI may cost more than multiple diagnostic tests, the use of non–evidence-based tests may inspire suboptimal practice with an undefined risk-benefit ratio.

Two seminal studies (NEXUS and Canadian Cervical Spine Rules [CCR])^46,47 have examined whether clinical criteria (neurologic deficit, cervical spine tenderness, intoxication, decreased mental status, and distracting injuries) can rule out CSI in adults without the need of imaging. These criteria have been applied to pediatric patients in a manuscript by Viccellio and colleagues,⁴⁸ who evaluated 3,065 blunt trauma patients younger than 18 years and found that nearly 20% of patients fell into the “low-risk” category where imaging could have been avoided. In another retrospective review of 206 pediatric patients (from birth to 16 years of age), Jaffe and colleagues⁴⁹ suggested that the absence of eight clinical criteria (neck pain; neck tenderness; abnormality of reflexes, strength, or sensation; direct trauma to the neck; limitation of neck mobility; abnormal mental status) enabled a clinician to detect CSI in children with a sensitivity of 98% and a specificity of 54%. The PECARN group has also reported on its series of 540 cervical spine injuries in children, presenting a model with eight predictors to identify children who should be evaluated for CSIs after blunt trauma.⁵⁰ These include altered mental status, focal neurologic deficits, complaint of neck pain, torticollis, substantial torso injury, predisposing condition, diving, and high-risk motor vehicle crash, with a sensitivity of 98%.

Location of Injury

Conventional wisdom has taught that the position of a CSI in children was related to age with the predominance of upper c-spine injuries seen in infants and toddlers and lower c-spine injuries seen in adolescents. This was thought to be a result of the mechanism of injury (flexion/extension and axial load, respectively). However, in a recent evaluation of the pediatric national trauma database, Polk et al.⁵¹ identified a greater percentage of injuries to the lower c-spine than previously reported. A large database study evaluated the tendency for injuries to occur at certain levels of the cervical spine over a 5 year period and found that younger children (≤10 years of age) sustained upper (C1–C4) CSI more frequently than lower (C4–C7) CSI (87% vs. 57%).⁴⁹ Data from a 24-year retrospective study of patients admitted with CSI to a level 1 trauma center similarly concluded that for younger patients (≤8 years of age), significantly more injuries occurred in the upper cervical spine.⁴⁶ However, the National Trauma Data Bank (NTDB) data for this study revealed that the number of fractures to the upper c-spine and lower c-spine was nearly equal (53% and 47%), and that more than half of cervical spinal cord injuries were located in the lower c-spine (53%).⁵¹

Mechanism of Injury

Motor Vehicle Crash (MVC) remains the most common mechanism of CSI for the youngest age group.^46–49,52 A study of children younger than 14 years observed that while MVC was the most common mechanism for this large age group, when ages were further stratified, MVC ranked the highest for infants.⁵³ This same study also found that falls were the most common mechanism for the 2 to 9 years age group. While the focus on children younger than 3 years in this study was unique, conclusions about mechanism of injury remained consistent with previous literature. The frequency of MVC as mechanism for blunt trauma CSI is significantly greater than all other mechanisms, with falls ranking second (66% and 15%, respectively). Given that this patient population is just learning to walk, falls are a concern. However, the high energy of an MVC has greater potential for major neurologic impairment and mortality.

The observations generated from analysis of the NTDB data suggest that the lower C-spine needs to be adequately evaluated on the basis of the near equal distribution of injuries. In addition, the association of CSI with high-energy mechanisms (i.e., MVAs) warrants a higher index of suspicion of this subset of young pediatric patients. In addition, those patients requiring at scene intubation and/or admission to the intensive care unit (ICU) should also be evaluated thoughtfully. Despite the low incidence of CSI, until the cervical spine is cleared, it should be immobilized, ideally with an age/size appropriate hard collar. Such collars should be stocked in all trauma centers that care for pediatric patients.

The authors of the reviewed paper⁵³ implemented a similar clinical guidelines strategy emphasizing the use of physical examination and NEXUS criteria in order to clear the cervical spine in children presenting after trauma. The primary outcome measure was to determine the use of CT scans in children younger than 15 years and to compare the extent of use of CT scans for cervical spine clearance 12 months before and after implementation of these guidelines. A total of 233 children were evaluated during the 2-year period (128 before guidelines were in place and 105 afterward). For children clearable by NEXUS criteria, the implementation guidelines had an immediate effect, decreasing CT use by 23%. Furthermore, there were no missed injuries. These results offer even more evidence that much of the imaging that is done to clear the c-spine in a child is unnecessary. The clinical evaluation of pediatric trauma patients with suspected c-spine injury is quite effective in predicting which subset of patients will benefit from cross-sectional imaging. Simple clinical criteria, like GCS, used in concert with the physical examination, can safely predict CSI in children, safely reducing the dependence on clinical imaging for the vast majority of patients (even the very young).

Spinal Cord Injury without Radiographic Abnormality

Spinal cord injury without radiographic abnormality was first defined in a series of children with signs of acute traumatic spinal cord injury in the absence of bony findings on cervical spine radiographs, flexion–extension films, or CT scans.⁵⁴ The authors noted that these patients had neurologic deficits or a history of transient paresthesias, numbness, or paralysis, and a delay of symptoms occurred in approximately half of the patients.

In recent years, as attention to limit ionizing radiation exposure in children has increased, magnetic resonance imaging has become a mainstay in the workup of children with presumed CSI or neurologic deficits on physical examination. As a result, more children have been found to have demonstrable injury to the spinal cord, soft tissue components of the spinal column vertebral body growth plates.^55,56 As a result of this advent of new neuroimaging paradigms, the diagnosis of spinal cord injury without radiographic abnormality has become questionable. Although the trend in the workup has been to limit radiography in children (with good reason), it is important to remember that young patients with blunt trauma who have a history of any transient neurologic symptom may have a significant injury to the spinal cord and/or spinal column, and these children warrant thorough radiographic evaluation.

Cerebrovascular Injury

Blunt trauma force to the neck or cervical spine fractures can result in vascular injuries to the carotid or vertebral arteries. Stroke and permanent neurologic deficit is the most feared outcome from this rare injury, and in children, because of ill-defined screening criteria, neurologic deficit is the most common presenting symptom for diagnosis. 2010 EAST guidelines are aimed at adult patients and provide little evidence toward screening criteria or management in either adults or children.⁵⁷ Risk factors for cerebrovascular injury include injury mechanism with severe hyperextension or hyperflexion with rotation, maxillary or mandibular injuries, TBI with diffuse axonal injury, near hanging, “seat belt sign” or other soft tissue contusion to the neck, and fractures involving the carotid canal or cervical vertebral body, particularly the vertebral foramen. A recent meta-analysis of pediatric blunt cerebrovascular injury recommended screening high-risk pediatric patients with CT angiography of the neck and treatment with anticoagulation in patients with confirmed injuries.⁵⁸

Thoracic Trauma

Blunt trauma, most commonly from motor vehicle crashes, is the most common mechanism for thoracic trauma in pediatric patients. Children have a more flexible, cartilaginous rib cage, and, therefore, serious intrathoracic injuries can occur in the absence of obvious external trauma or rib fractures. Children also have a more mobile mediastinum, predisposing them to tension pneumothorax with subsequent cardiopulmonary collapse from impaired venous return. The primary survey is designed to identify these acute life-threatening thoracic injuries such as airway injury, tension pneumothorax, open pneumothorax, hemothorax, flail chest with pulmonary contusion, or cardiac tamponade, which require immediate intervention (Table 29-6).⁵⁹ Once bilateral breath sounds and adequate ventilation and oxygenation are confirmed, CXR is an urgent part of any pediatric trauma evaluation and can identify most other acute thoracic injuries. FAST examination can evaluate for pericardial fluid and in experienced hands can identify pneumothorax or pleural effusion. Many injuries can be observed or managed with tube thoracostomy.

Pulmonary contusions are one of the most common thoracic injuries after blunt trauma. The diagnosis is made on CXR in which infiltrates are identified that do not follow anatomic boundaries. Parenchymal edema peaks at 24 to 36 hours postinjury, as the contusion “blossoms” on CXR, and requires admission for monitoring, oxygen therapy, or intubation and respiratory support if needed. Any evidence of hemothorax or pneumothorax seen on CXR should be managed initially with tube thoracostomy. Stable patients with an occult pneumothorax (seen only on CT scan but not on CXR) may be safely observed without thoracostomy drainage, even if requiring positive pressure ventilation. Traditional indications for thoracotomy in adults include an initial chest tube output of 1,500 mL and a persistent output of 150 to 200 mL/hr for 4 hours. In children, this equates to a chest tube output of approximately 20% of the patient’s estimated blood volume, or ongoing output of 2 to 3 mL/kg/hr. However, patient physiology should be the primary indication for surgical treatment rather than the absolute blood output. The thoracoscopic approach has become increasingly acceptable in stable patients for the management of retained hemothorax, persistent air leak, or select diaphragmatic injuries after penetrating thoracoabdominal trauma. The EAST practice management guidelines for thoracic trauma provide a good overview of the evidence for management of thoracic trauma in adults, but no specific guidelines exist for pediatric patients.⁶⁰

Emergency bedside thoracotomy is indicated for patients who present pulseless to the emergency department with signs of life and penetrating thoracic trauma. The evidence is more controversial for patients who do not have signs of life or who sustained penetrating extrathoracic injuries or blunt trauma and should be based on clinical judgment. There is no role for emergency thoracotomy for patients without signs of life after blunt trauma.⁶¹ Advanced trauma life support guidelines recommend application of these guidelines to children on the basis of existing literature,^62,63 but these data are sparse.

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