Chest injuries in children

Chest injuries of varying severity occur commonly in children, much more as a result of motor vehicle accidents and falls from a height than from penetration. The author reviews the injuries that occur with reference to mechanism, immediate and late treatment and monitoring. The differences between the injuries of children and those of adults stem from the greater resilience of most structures in children; bony injuries are not necessarily extensive even when disruptions of the lung and blood vessels are serious. Pneumothorax may occur alone or with other injuries. A chest tube should be inserted early. Persistence of the pneumothorax may indicate the presence of a tracheobronchial tear which must be repaired by thoracotomy. A flail chest may be treated without intubation if blood-gas levels are normal. In the presence of paradoxical motion and increased carbon dioxide pressure, intubation and positive-pressure ventilation are required for a few days. Penetrating wounds require the same care as in adults. Diaphragmatic tears occur from falls from excessive heights or direct passage of vehicle wheels over the chest or abdomen. Ventilation becomes progressively more inefficient. Esophageal tears occur from irregular foreign bodies. Great-vessel injuries occur by penetration. The author establishes priorities in management to assure adequate oxygen utilization, arrest of hemorrhage and restoration of circulation. Following stabilization efforts, monitoring procedures are instituted. These include insertion of central venous pressure and arterial lines to measure pH, carbon dioxide and cardiac output as well as for other biochemical and hematologic measurements.