Age
Weight (kg)
Chest tube size (Fr.)
Newborn to 1 year
3–5
10–12
≥1–2 years
6–9
12–16
3–4 years
10–11
16–20
12–14
20–22
5 –7 years
15–18
22–24
19–22
24–28
8 –11 years
23–30
28–32
≥12 years
>30
32–42
(iii)
Operation (thoracotomy) is indicated when:
1.
The initial thoracostomy tube output is greater than or equal to 20–30 % of the blood volume.
2.
The output is greater than 2–3 mL/kg/h over 6 h.
3.
Significant hemorrhage occurs.
(b)
Pneumothorax, tension:
(i)
In most cases, pneumothorax occurs due to small disruptions of lung parenchyma, associated with small to modest air leaks.
(ii)
Increased mobility of the mediastinum in children can create a higher risk for physiologic consequence.
(iii)
Needle decompression with large-bore over-the-needle catheters should be used with caution in infants and small children due to the longer needle length entering a thinner chest wall.
(iv)
Chest tube placement is the definitive treatment for pneumothorax in most cases.
(c)
Rib fracture:
(i)
Rib fractures are far less common in children versus adults, and serve as an important marker of injury severity. When present, rib fractures in children are associated with a mortality rate of 42 %.
(ii)
First and second rib fractures in children are associated with cervical spine injury, pulmonary contusion, and injury to intrathoracic vessels.
(iii)
Pulmonary toilet is essential in preventing atelectasis and pneumonia. Adequate analgesia is an important adjunct to facilitate pulmonary toilet, and may include epidural or intercostal nerve blocks.
(d)
Sucking chest wound:
(i)
Often associated with a lung parenchyma injury as well, and should initially be addressed with a “flutter-valve” occlusive dressing in order to prevent tension pneumothorax. This is accomplished by taping only three sides of a four-sided occlusive dressing.
1.
Chest tube placement (at a site other than the open chest wound) should then be performed as soon as possible.
(e)
Thoracic vascular injury:
(i)
The most common (and lethal) thoracic great vessel injury is traumatic aortic disruption. Work-up and surgical repair (when applicable) should not be delayed.
1.
Presentation: midcapsular back pain, unexplained hypotension, upper extremity hypertension, bilateral femoral pulse deficits, and large initial chest tube outputs.
2.
Radiographic findings (plain x-ray): widened mediastinum, blurring of the aortic knob, deviation of a nasogastric tube, abnormal paraspinous stripe, rightward tracheal deviation, or upward shift of the left main stem bronchus. The thymus in younger patients can sometimes mask these findings.
3.
Diagnostic imaging: Options include helical CT (typically preferred), TEE, CT angiography, and aortography.
(f)
Cardiac injury:
(i)
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Myocardial contusion:
1.
Most common cardiac injury in children.
2.
May resemble myocardial infarction, supraventricular arrhythmia, or ventricular arrhythmia.
3.
Often associated with pulmonary contusion and rib fractures.
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