Injury patterns (Pneumothorax (simple or tension), hemothorax, pulmonary contusion, rib fractures — may present without external wound; children have compliant chest wall — significant internal injury with minimal external signs (ATLS pediatric, WHO))
First-line therapy
Chest decompression • procedure
Duration: Once · 14–16 G angiocath — 2nd ICS MCL or 4th/5th ICS AAL; immediate for tension PTX; follow with chest tube (ATLS pediatric, ERC)
• **Tension pneumothorax:** absent breath sounds, hyperresonance, tracheal deviation (late), hemodynamic compromise — immediate needle decompression 2nd ICS MCL or 4th/5th ICS AAL; do NOT delay for CXR (ATLS, ERC).
• **Simple pneumothorax:** decreased breath sounds, mild distress — supplemental O₂, CXR confirmation; observe small PTX if stable and minimal symptoms; chest tube if large, symptomatic, or ventilated (ATLS pediatric).
• **Pulmonary contusion:** hypoxia out of proportion to exam, hemoptysis — O₂, lung-protective ventilation if intubated; serial CXR; may worsen over 24–48 h; see blast_injury for primary blast lung overlap (ATLS, WHO).
• **Hemothorax:** dullness, decreased breath sounds — chest tube if >150–200 mL initial output or ongoing bleeding; massive hemothorax → blood products and surgery (ATLS).
• **Analgesia:** rib fractures — weight-based analgesia (morphine, ibuprofen if no contraindication); splinting worsens atelectasis — encourage deep breathing when safe (ATLS, WHO Pocket Book).
Chest tube + admission / trauma surgery • procedure
Duration: ED / inpatient · Chest tube insertion for hemothorax, large PTX, or open pneumothorax after seal; admit if abnormal vitals, large PTX, hemothorax, pulmonary contusion with hypoxia, or multisystem trauma (ATLS, pediatric trauma)
• **Chest tube indications:** large or symptomatic pneumothorax, hemothorax, open pneumothorax after temporary seal, need for positive pressure ventilation (ATLS).
• **PICU:** intubation for respiratory failure, severe pulmonary contusion, ARDS — lung-protective ventilation 6–8 mL/kg IBW; see blast_injury for blast lung PEEP precautions (ATLS, ERC).
• **Surgery:** persistent hemothorax >1500 mL/24 h, ongoing bleeding, cardiac tamponade suspicion — emergent thoracotomy per trauma team (ATLS).
• **Antibiotics:** NOT routine for closed blunt chest trauma without open wound — reserve for penetrating/open chest injury variant (ATLS).
Clinical notes
• ABCDE: inspect chest wall, auscultate breath sounds, assess work of breathing and SpO₂; tension PTX is a clinical diagnosis — treat before imaging (ATLS pediatric).
• Children: rib fractures uncommon — their presence suggests high-energy mechanism; pulmonary contusion may be sole finding (ATLS, pediatric trauma).
• CXR: initial and serial if deteriorating; FAST does not replace CXR for thoracic injury; CT chest per trauma team in polytrauma (ATLS).
• Admission criteria: hypoxia, large PTX/hemothorax, pulmonary contusion, abnormal vitals, concurrent injuries, or social concerns — observe minimum 12–24 h for occult deterioration (ATLS).
• ATLS — Thoracic trauma and chest tube management (2024)
• ERC — Paediatric life support (tension pneumothorax) (2021)
• WHO — Pocket Book of Hospital Care for Children (chest injury) (2022)
