Chest trauma in children can result in serious injuries and poor outcomes. Managing chest injuries in children can be challenging, but being prepared makes all the difference. This overview will guide you through the key steps in assessing and managing paediatric chest trauma, with practical tips to help you stay ahead in those high-stakes moments.
Olly and Milly, both new to golf, were practising their swings at home with their dad’s golf club. Mid-swing, Milly accidentally struck Olly in the chest. He immediately felt a sharp pain, spotted blood at the site of impact, and noticed a hissing sound with every breath.
Their dad, hearing the commotion, rushed in to find Olly pale, clutching his chest, with air visibly escaping from the wound. He dialled 999 without hesitation. An ambulance was quickly dispatched.
Why do we worry about chest trauma?
Paediatric chest trauma accounts for just 5–15% of all trauma admissions, but its impact is far greater than the numbers suggest. Incidence varies globally, influenced by factors such as road safety laws, age-related activities, and rates of interpersonal violence.
When it does occur, chest trauma is linked with significantly higher morbidity and mortality compared to other injuries. Outcomes are even worse in children with polytrauma, those with chest injuries alongside other trauma.
For any clinician caring for seriously injured children, recognising and managing chest trauma promptly is vital.
Why is chest trauma different in children?
Children aren’t just small adults. Their anatomy and physiology are markedly different, and these differences are even more pronounced in infants and younger children. These variations have a major impact on how chest trauma presents, how it’s investigated, and how it’s managed. This leads to distinct patterns of chest injuries that can occur in children compared to adults.
For starters, children’s ribs are very elastic. The chest wall needs vast amounts of force to fracture ribs. Even without obvious chest wall injuries, clinicians must be aware that this does not exclude major injuries. The ribs and sternum are not ossified in children. This results in less protection for underlying structures, and more force is transmitted to the underlying organs. A high index of suspicion is essential—even in the absence of bruising, deformity, or wounds. What you don’t see can still be life-threatening.
Children can compensate well—until they can’t. Their limited physiological reserve and higher metabolic rate mean they desaturate much faster than adults. Hypoxia can develop quickly, and once it does, deterioration can be rapid.. Furthermore, they have less fat and connective tissue, further reducing the barrier between outside forces and the vital organs. Because of this, chest injuries can quickly lead to impaired oxygen transfer and acute tissue hypoxia.
During trauma, children often swallow air—a phenomenon known as aerophagia—which can lead to significant gastric distension. Add to that a potential trauma-related ileus, and you’ve got a distended abdomen that can push up against the diaphragm, further compromising breathing. Gastric distension can significantly compromise lung capacity, so early placement of a gastric tube is paramount.
Children with chest trauma often have trauma elsewhere, including the brain. Children have proportionally smaller chests but larger heads and abdomens than adults. This makes them more vulnerable to multisystem trauma. So, if you’re dealing with a paediatric chest injury, don’t stop there. Always think beyond the chest and look for associated head, abdominal, or spinal injuries.
The last key difference is often drilled into us, but it is vital to remember: hypovolaemia can be easily masked. Hypotension is a pre-terminal sign.
The pre-hospital team find an 8-year-old boy with a sucking chest wound on the left anterior chest. They applied a three-way seal and transported him to the Emergency department. There is approximately 100 ml of blood loss noted.
Preparing the team for the arrival of the injured child
When managing paediatric trauma, the priority is identifying and treating life-threatening injuries. Preparation is pivotal in stabilising the patient, conducting focused imaging, and providing interventions. Priorities can be organised into three categories: Team, Environment, and Equipment.
Team
When paediatric chest trauma is suspected, don’t wait—initiate a trauma call early. A coordinated team approach to the primary survey is essential. This typically involves a paediatric anaesthetist, surgical teams, and the paediatric intensive care team.
An early team brief sets the tone for focused, efficient care, with the paediatric emergency clinician leading the charge. Advance communication with key departments—such as theatres and the blood bank—can save vital minutes, ensuring crossmatched blood and operating space are ready if needed..
You might want to activate the major haemorrhage protocol before arrival, ensuring early access to blood products. However, this process often varies across hospitals.
In high-stakes situations, every second—and every decision—counts. Reduce cognitive load by using trust guidelines, standard operating procedures, and pre-prepared, weight-based drug charts. Having these ready to go before the patient arrives can make a huge difference when the pressure’s on.
Preparation is power.
Environment
Preparing a resuscitation bay with appropriate monitoring is fundamental for managing major trauma, including those with isolated chest injuries, as unanticipated injuries may necessitate more resources than anticipated. Conducting a team brief within a resus cubicle fosters a shared mental model of care.
Equipment
Standard monitoring aside, anticipate worst-case scenarios and prepare accordingly. This includes airway (e.g., video laryngoscopes), chest drain, and thoracotomy kits, available before patient arrival. Since resuscitation bays are often stocked for adults, having age-appropriate monitoring and equipment ready (e.g., ETCO2 monitoring), can reduce delays.
Thinking about the temperature. Children become hypothermic quickly due to their larger body surface area relative to weight, so implement active warming strategies to maintain normothermia.
Patient arrival
When the patient arrives, the immediate goal is to identify and address life-threatening injuries before a structured handover. Ensuring a seamless transition between handover and definitive care is critical to achieving a good outcome.
Having received the pre-alert, you have briefed the team, allocated roles, and prepared the resuscitation bay. On arrival, Olly is stable enough for the pre-hospital team to give a structured handover.
Imaging in chest trauma
Unlike imaging in adult trauma, where whole-body CTs are often done to detect life-threatening injuries, we prefer a more focused approach when imaging paediatric chest trauma. Children and young people often have different injury patterns compared to adults, and they’re also more sensitive to the effects of radiation. This should factor into your decision-making when considering imaging, especially CT scans.
Choose the right modality for the right reason, and always weigh up the diagnostic benefit against the potential long-term risks.
n children and young people, the chest wall and mediastinal structures are more elastic than in adults. That means rib fractures and aortic injuries are less common—but the lungs are more vulnerable to direct impact.
Pulmonary contusions and other internal injuries are more frequent, even when the chest appears externally uninjured. Fortunately, most injuries that require further management are visible on a chest x-ray. While subtle findings like small contusions might not be picked up, these are usually self-limiting and managed conservatively.
A normal chest X-ray is generally reassuring—it’s a good tool for ruling out clinically significant thoracic injury.
Guidelines published by the Royal College of Radiologists (RCR) in 2024 recommend a chest X-ray as the first line for blunt trauma imaging, with further imaging guided by the nature of the injury, haemodynamics (heart rate and blood pressure), and chest X-ray findings.
Not every blunt chest injury needs a CT, but it should be high on your list in certain scenarios.
Consider a contrast-enhanced CT when there’s potential for high-energy trauma, such as:
- Falls from height (>6 metres)
- High-speed RTCs (>40 mph)
- Rapid deceleration injuries
Also think CT when clinical assessment is limited—for example, if the child has:
- A reduced GCS
- Intoxication
- A painful, distracting injury
These factors increase the risk of missed injuries and may justify early cross-sectional imaging.
For penetrating injuries, the RCR guidelines recommend a contrast-enhanced CT to rule out vascular injury that may not show up on a CXR.
A portable chest x-ray, performed during the primary survey, confirms a large haemopneumothorax. Fortunately, your early team brief has everyone ready. You ask your anaesthetic colleague to prepare for sedation while the emergency medicine team sets up to insert a chest drain.
The procedure goes smoothly. A subsequent CT scan shows no evidence of vascular injury—reassuring news in a potentially life-threatening situation.
The management of blunt and penetrating chest trauma
Chest injuries are typically classified as either blunt or penetrating. In children, the proximity of vital structures within the chest means that even a single injury can result in multiple underlying problems.
This makes a thorough primary survey essential. Don’t assume it’s “just” a rib injury or “just” a wound—look deeper, and consider the full range of potential thoracic injuries.
Children presenting with respiratory failure may have a tension pneumothorax, open pneumothorax, haemothorax, or pulmonary contusions.
Initial management strategies may include:
- Advanced airway management to optimise ventilation
- Needle decompression or tube thoracostomies.
- Applying a three-sided dressing to open chest wounds prevents tension pneumothorax from an open pneumothorax.
For patients presenting with circulatory collapse due to chest injuries, the causes may include tension pneumothorax, massive haemothorax or cardiac/great vessel injuries.
Management in these scenarios may require:
- Massive haemorrhage transfusion protocol to address hypovolaemia
- Needle thoracocentesis for a tension pneumothorax
- Pericardiocentesis for tamponade
- In rare cases, an emergency clamshell thoracotomy
To simplify the management of chest trauma, we can divide care into two broad categories: supportive and specific care.
Supportive care
Children who present with significant chest injuries require close monitoring and symptomatic management. Key aspects of this care include:
- Supplemental oxygen to optimise oxygenation
- Pain management strategies to reduce discomfort and improve breathing mechanics
- Continuous monitoring for early detection of deterioration
Specific care
Management becomes more targeted based on the underlying injury.
Chest decompression
Prompt intervention is key in conditions like pneumothorax and haemothorax. Techniques such as needle decompression, intercostal chest drain insertion, and supportive care with oxygen and fluid resuscitation form the cornerstone of management.
Knowing when—and how—to act can make all the difference.
1. Needle decompression: A rapid intervention to relieve tension pneumothorax while preparing for a pigtail or tube thoracostomy.
2. Pigtail catheter: Evidence supports using pigtail catheters for managing pneumothoraces. They are similar in efficacy to tube thoracostomy and reduce pain, and they are currently gaining favour.
3. Tube thoracostomy: This procedure is indicated for traumatic haemothorax. Local guidance should be used to determine appropriate tube sizes, with larger tubes typically required for haemothoraces.
Emergency Thoracotomy
Resuscitative thoracotomy deserves special mention—not because it’s common, but because when it’s needed, it’s life-saving. It’s a rare and complex procedure, reserved for children in decompensated shock following penetrating chest trauma.
Whenever possible, these patients should be taken straight to theatre. But in extreme cases, where delay would be fatal, thoracotomy may be performed in the emergency department by an experienced team.
It’s a high-stakes decision that requires clear protocols and senior support.
In rare cases, Emergency Department thoracotomy may be performed for patients in extremis, such as those in cardiac arrest. The primary goals here are:
- To relieve cardiac tamponade
- To control catastrophic haemorrhage.
This high-risk procedure should ideally be undertaken by experienced trauma or paediatric surgeons. Following stabilisation, these patients will require operative intervention for definitive care.
Emergency Surgery
While emergency surgery is beneficial for some children with chest injuries, the need for this is still, fortunately, rare.
Following chest drain insertion, Olly was transferred to the PICU for observation and later to the ward. His sister and family were able to visit him on the ward. After a few days on the ward, Olly was discharged.
Trauma aftercare
The impact of injuries doesn’t stop when the child or young person leaves the hospital, and as such as we need to take a trauma-informed approach to their care.
Major trauma doesn’t end with survival. For many children and young people, the impact is long-lasting—physically, psychologically, and emotionally. These effects can profoundly influence quality of life, education, relationships, and overall social functioning.
Nearly half of young people who survive severe injury show symptoms of post-traumatic stress disorder (PTSD). Standard inpatient care often falls short in addressing these complex, ongoing needs.
That’s why a coordinated, multidisciplinary approach to trauma aftercare is essential—and increasingly recognised as best practice in international guidelines.
The impact of serious injury extends far beyond the child or young person. Families, caregivers, and even peers can experience significant emotional distress in the aftermath of trauma.
These individuals are not just bystanders but a vital part of the child’s support system. Involving them in recovery isn’t just compassionate—it’s clinically important. Trauma support services that actively include families are linked to improved quality of life and better outcomes for young people.
Don’t forget to signpost support for parents, siblings, and carers. Healing is a team effort.
Aftercare isn’t just about healing a chest wall—it’s about helping the child or young person reach their full potential after trauma. The goal is to restore the best possible quality of life, with support for physical, psychological, and social recovery.
While clinicians often lead on follow-up for specific injuries, like ensuring resolution of a pneumothorax or managing ongoing chest pain, the wider team is just as crucial. This often includes psychologists, play specialists, physiotherapists, and occupational therapists.
Rehabilitation is rarely a solo act. It’s a multidisciplinary effort that continues well beyond discharge.
Take a look at the AfterTrauma website created by the Centre for Trauma Sciences at Queen Mary University of London. You may also have similar local examples in your area.
Olly and his family were referred to the aftercare team. They received counselling related to the events of the injury and the hospital stay.
Although tentative at first, he is now back at school, and both he and his sister are excited to join their dad in playing golf.
Take-home points
Chest trauma in children is rare but is associated with significant morbidity and mortality.
Children display distinct injury patterns compared to adults, necessitating a high index of suspicion for chest injuries, even in the absence of obvious external signs of injury.
Chest injuries can rapidly lead to impaired oxygen transfer and, consequently, acute tissue hypoxia. It is crucial to remember that hypotension may indicate a pre-terminal state.
Preparing the team, environment, and equipment for the arrival of an injured child is essential.
Generally, a chest x-ray is the first-line imaging for blunt trauma, while penetrating injuries require a contrast-enhanced CT.
It’s not enough to just recognise chest injuries—we need to be ready to act. Be familiar with the key procedures that may be needed in managing a child with thoracic trauma.
The impact of injury extends far beyond the hospital stay. Recovery is physical, psychological, and social—and it affects not just the child, but their whole support network. Holistic, family-centred care is essential.
Now see how you manage Tarquin.
References
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Chen Q, Huang G, Li T, et al. Insights into epidemiological trends of severe chest injuries: an analysis of age, period, and cohort from 1990 to 2019 using the Global Burden of Disease study 2019. Scand J Trauma Resusc Emerg Med. 2024;32(1):89. Published 2024 Sep 16. doi:10.1186/s13049-024-01258-2
Cintean R, Eickhoff A, Zieger J, Gebhard F, Schütze K. Epidemiology, patterns, and mechanisms of pediatric trauma: a review of 12,508 patients. Eur J Trauma Emerg Surg. 2023;49(1):451-459. doi:10.1007/s00068-022-02088-6
Eisenberg, M. Thoracic trauma in children: Initial stabilisation and evaluation. UpToDate. 2025. Available online at https://www.uptodate.com/contents/thoracic-trauma-in-children-initial-stabilization-and-evaluation
Lopez MD. Evaluation and management of paediatric chest trauma. Emergency Medicine Reports. 2008 Mar 30.
Ostermann RC, Joestl J, Lang N, et al. Thoracic Injuries in Pediatric Polytraumatized Patients: Epidemiology, Treatment and Outcome. Injury. 2021;52(6):1316-1320. doi:10.1016/j.injury.2021.02.033
Pearson EG, Fitzgerald CA, Santore MT. Pediatric thoracic trauma: Current trends. Semin Pediatr Surg. 2017;26(1):36-42. doi:10.1053/j.sempedsurg.2017.01.007
Sweet, A et al. Epidemiology and outcomes of traumatic chest injuries in children: a nationwide study in the Netherlands. Eur J pediatr 2023. Apr;182(4):1887-1896
