In the absence of an intra-abdominal source of hemorrhage or cardiac
tamponade, a chest tube should be placed in the affected side of the chest to
directly assess for hemothorax. With initial placement of the chest tube blood
will immediately evacuate and the initial output should be noted. Initial volume
out of a chest tube that is greater than 20 ml/kg of bleeding, especially if the
bleeding persists, may warrant emergent thoracotomy in the operating room to
control the bleeding.
If tension pneumothorax and massive hemothorax are absent and the
patient remains hemodynamically unstable despite appropriate fluid
resuscitation, the patient should be evaluated for cardiac tamponade. This is
particularly important in a patient who has suffered a penetrating injury in the
region of the “cardiac box.” A FAST exam or echocardiogram (ECHO) should
be performed to evaluate for pericardial effusion. Confirmation of fluid in the
pericardial sac demands emergent exploration in the operating room. In the
event that the patient is too unstable to transfer, a temporizing
pericardiocentesis may be performed at the bedside in the ED.
Rarely, a child with severe thoracic trauma may lose vital signs upon
arrival to the ED or during resuscitation. If the patient has suffered a
penetrating injury to the chest, emergent ED thoracotomy may be indicated. In
blunt trauma, however, emergent thoracotomy should be avoided as it is almost
uniformly futile.
C. Emergency Room Thoracotomy