Assessment and management of thoracic injuries
Aim: The trainee should have an understanding of common injuries to the chest of a child
including the work-up and initial management of such patients.
Objectives:
Knowledge objectives:
The trainee should have acquired the following knowledge:
 An understanding of the anatomy of the chest wall and intrathoracic viscera
 An understanding of the pliability of the chest wall in younger children, such that internal
injuries may occur without evidence of injury to the thoracic cage.
 An understanding of the increased predisposition of children to hypoxia due to:
o Airway is more prone to obstruction
o Low functional residual capacity
o Predominant use of diaphragm for breathing
o Susceptibility to pulmonary contusion.
o Relative ease of displacement of an endotracheal tube due to short length of the
trachea
o Relatively high mobility of the mediastinum, with a subsequent higher
predisposition of rapidly developing tension
 An understanding of the relative risks of certain injury patterns relative to adults:
o Increased risk of pulmonary contusion
o Increased risk of tension with a pneumo- or hemothorax
o Lower risk of great vessel and esophageal injury
 An understanding of the mechanism, pathophysiology and clinical presentation of
traumatic asphyxia
 An understanding of the radiologic findings and management of pulmonary contusion
 An understanding of the clinical findings during the primary survey of a:
o tension pneumothorax
o simple pneumothorax
o open pneumothorax
o Flail chest
o Massive hemothorax
o Cardiac tamponade
o Airway obstruction
 Know the management principles for the treatment of life-threatening injuries during the
primary survey, including
o Needle decompression
o Chest tube thoracostomy
o Intubation
o Pericardiocentesis
 An understanding of the clinical and radiologic findings of a:
o simple pneumothorax
o Hemothorax
o Pulmonary contusion
o Tracheobronchial disruption
o Blunt cardiac injury
o Traumatic diaphragmatic injury
o Possible aortic injury
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Differentiation of the pathophysiology between a simple, open and tension pneumothorax
Initial management of a patient with a simple, tension or open pneumothorax
Management of a massive hemothorax
Know how to identify clinically significant blunt cardiac injury using ECG or appreciate
the role of echocardiography in making the diagnosis.
Initial management of a patient suspected of having a cardiac tamponade
Mechanisms of injury and clinical and radiologic indices that raise suspicion for an aortic
injury
Management of penetrating injuries in general
Demonstrate a knowledge of the radiographic assessment for blunt aortic injuries.
Indications for emergency thoracotomy (not in the ED)
o Penetrating wound of the heart or great vessels
o Massive or continuous intrathoracic bleeding
o Open pneumothorax with major chest wall defect
o Evidence of injury to aorta or major vascular branch thereof
o Massive on -going airleak indicating injury to a major airway
o Cardiac tamponade
o Esophageal perforation
o Diaphragmatic rupture
o Penetrating chest trauma with persistent hypotension despite maximal
resuscitation
Indications for Emergency Department thoracotomy
o For post-traumatic witnessed arrest or near arrest if:
 Penetrating thoracic trauma
 Blunt trauma with acute deterioration but signs of life initially in the ED
Skills objectives:
 The trainee should have an understanding of the following skill set:
 A systematic way to review a supine AP chest xray
 An ability to identify on CXR major thoracic injury radiologic features:
o Rib/clavicular fractures
o Pneumothorax – simple and tension
o Hemothorax
o Pulmonary contusion
o Widened mediastinum
 Performance of a needle thoracentesis for a presumed tension pneumothorax
 Insertion of a chest tube by an open technique or closed seldinger-type technique
 Know how to connect the tube thoracostomy system to suction
 Performance of a pericardiocentesis in the case of suspected cardiac tamponade
 Have an understanding of how to perform an ED thoracotomy