All trauma patients should receive supplemental oxygen. Assessment of breathing entails identifying inadequate oxygenation or ventilation or the potential for deterioration. Children with respiratory failure should have positive pressure ventilation (PPV) started immediately. PpV may render an innocuous pneumothorax into a compromising injury, and such a possibility should be actively monitored. If the presence of a small pneumothorax is already known, a tube thoracostomy may be appropriate early in the resuscitation efforts. Children with respiratory distress may not have a striking presentation, but still require immediate attention to minimize complications. Cyanosis, poor end-organ function, and desaturation on pulse oximetry will identify a child with severe hypoxemia. A child with mild hypoxemia may manifest more subtle signs, such as agitation and poor capillary refill. Signs of inadequate ventilation in the young child include tachypnea, nasal flaring, grunting, retractions, and stridor or wheezing. Often, signs of inadequate oxygenation and ventilation will coexist in children. Auscultation of the chest can identify a large pneumothorax or hemothorax. Because breath sounds are easily transmitted across a small chest, breath sounds should be sought in both axilla. If signs of inadequate oxygenation do not improve rapidly with high-flow oxygen administration, then PPV must be started.

TENSION PNEUMOTHORAX The classic presentation of a tension pneumothorax is absent breath sounds, tympany, hypotension, and jugular venous distention due to high intrathoracic pressures. Children rarely have this complete presentation. If suspected during the primary survey, a catheter decompression should be performed, followed by tube thoracostomy.

MASSIVE HEMOTHORAX The classic presentation of a massive hemothorax is absent breath sounds, dullness to percussion on the affected side of the chest, and hypotension. Jugular venous distention is unlikely because the circulatory volume is low. Tube thoracostomy is needed for effective management. Operative thoracotomy should be considered if the initial drainage is greater than 15 mL/kg or the chest tube output exceeds 4 mL/kg/h.

OPEN PNEUMOTHORAX The skin wound of an open pneumothorax should be occluded on three sides with a dressing of petrolatum gauze or a plastic sheet. An open pneumothorax may be associated with a tension pneumothorax. An occlusive dressing is applied and air can no longer escape through the wound; leaving one side of the dressing open to act as a flutter valve will minimize the development of a tension pneumothorax. A tube thoracostomy need only be performed after completing the primary survey.

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