Version May 2024
INTRODUCTION — This topic will review clinical manifestations and initial management of intrathoracic injuries in children. More detail regarding management of specific injuries is provided separately:
●(See "Initial evaluation and management of blunt cardiac injury", section on 'Pediatric considerations'.)
●(See "Thoracic trauma in children: Initial stabilization and evaluation".)
●(See "Pulmonary contusion in children".)
●(See "Chest wall injuries after blunt trauma in children".)
PNEUMO- AND HEMOTHORAX — Pneumothorax and hemothorax are among the most common intrathoracic injuries that occur in children [1]. They can result from blunt or penetrating mechanisms. Pneumothoraces can arise from chest wall injury or from injuries to the lung, trachea, bronchi, or esophagus; hemothoraces arise from injury to the blood vessels of the chest wall, mediastinum, or hilum. Both injuries can be life threatening and frequently occur together. Tension pneumothoraces lead to collapse of the ipsilateral lung and prevent venous return to the heart (see "Causes of acute respiratory distress in children", section on 'Tension pneumothorax'). Hemothoraces can lead to overwhelming blood loss and cardiovascular collapse.
Clinical manifestations — Children with hemo- or pneumothorax often complain of chest pain and shortness of breath. Physical examination may be notable for:
●Tachypnea
●Hypoxemia
●Respiratory distress
●Crepitus in the neck and/or chest
●Chest wall ecchymosis
●Diminished breath sounds on the affected side
●Paradoxical chest wall movement
●Hyperresonance to percussion
In addition to the signs above, tension pneumothorax, when present, leads to marked hypotension, distended neck veins due to blockage of extrathoracic venous return, and may cause tracheal deviation away from the affected lung.
Children with large hemothoraces may also demonstrate signs of hemorrhagic shock such as tachycardia, hypotension, narrowed pulse pressure, pallor, and/or poor perfusion. Examination of the chest may reveal dullness to percussion and diminished breath sounds on the affected side.
Diagnosis — The diagnosis of pneumo- or hemothorax is suspected based upon clinical findings and is confirmed during treatment by evidence of decompression such as a rush of air when the pleural cavity is entered during chest tube placement, evacuation of blood and/or air when the chest tube is connected to suction via a closed drainage system, or air obtained during needle thoracostomy. Improvement in vital signs and examination findings after thoracostomy and decompression also supports the diagnosis.
In stable pediatric patients, imaging (chest radiograph (image 1) or bedside ultrasonography) also can provide the diagnosis. However, in unstable patients, imaging should not delay emergency chest tube placement or, in patients with tension pneumothorax who are in extremis, needle thoracostomy (see 'Management' below):
●Supine chest radiograph – A screening supine chest radiograph is routinely obtained in patients with multiple trauma as part of the primary survey. Although highly specific for the presence of a pneumothorax, it lacks sensitivity for this critical diagnosis in the emergency department setting. In one retrospective observational study of 47 children with pneumothorax or hemothorax due to blunt trauma seen on computed tomography (CT) of the chest, supine radiography identified only 5 (11 percent) [2].
●Bedside ultrasonography – Limited evidence in pediatric trauma patients suggests that lung ultrasound may assist with rapid diagnosis of a clinically important pneumothorax but may not detect occult pneumothoraces and cannot quantify the size of the pneumothorax [3,4]. Additionally, bedside lung ultrasound (US) has been shown to be both sensitive and specific for the presence of spontaneous pneumothoraces in children without trauma [5]. US may also aid in identification of hemothorax and pericardial effusion.
While chest CT identifies intra-thoracic injuries missed by chest radiography, it infrequently changes management and should be reserved primarily for stable patients in whom there is a concern for an injury to a large blood vessel [6,7].
Management — Management of tension pneumothorax requires emergency needle thoracentesis performed with a large bore angiocatheter, followed by definitive placement of a pigtail catheter or tube thoracostomy. Tube thoracostomy is indicated for patients with traumatic hemothorax.
Pigtail catheter placement, rather than tube thoracostomy, may be appropriate for pneumothoraces without associated hemothorax. Evidence suggests that a pigtail catheter provides similar efficacy with less pain than a thoracostomy tube [8,9]. Finally, limited evidence suggests that, for patients with clinically occult asymptomatic pneumothoraces, observation without catheter placement may be associated with pneumothorax resolution and a shorter length of hospital stay [10].
For tube thoracostomy, the appropriate size chest tube may be determined by the child's age and/or weight (table 1). The technique for performing the procedure is described separately (figure 1). (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)
Management of larger hemothoraces may also require blood transfusion. Blood should be available at the time of thoracostomy because placement of the tube can disrupt clots and lower pleural pressure that may result in increased bleeding. Blood drained from the pleura can also be collected and autotransfused. For bleeding that continues at a rate of greater than 1 to 2 mL/kg/hr, thoracotomy is usually indicated. The indications for emergency department thoracotomy in children with thoracic trauma is provided separately. (See "Thoracic trauma in children: Initial stabilization and evaluation", section on 'Emergency thoracotomy'.)
PULMONARY CONTUSION — Pulmonary contusion is defined as pulmonary parenchymal damage with edema and hemorrhage, in the absence of an associated laceration of a large pulmonary vessel. In children with blunt trauma, pulmonary contusions typically arise in the posterior lung from shear forces applied across a deformable chest wall. Clinical features may be subtle and include tachypnea, hypoxemia, and/or respiratory distress. Physical examination findings of pulmonary contusion may include chest wall ecchymosis, rales, rhonchi, or decreased breath sounds, but the examination is frequently normal in affected children. Supine chest radiography should be performed for all children with suspected pulmonary contusion and all significantly injured children. The primary finding consists of nonanatomic areas of consolidation that are located in the region of impact (image 2). Associated injuries such as pneumothorax, hemothorax, or, less commonly, rib fractures may also be apparent. (See "Pulmonary contusion in children".)
The management of pulmonary contusion is discussed separately. (See "Pulmonary contusion in children", section on 'Management'.)
PULMONARY LACERATION — Pulmonary lacerations occur rarely in children. In a large retrospective series describing truncal injuries in children, 2 percent of the injuries were pulmonary lacerations, with a mortality rate of 55 percent [1]. Pulmonary lacerations are caused by penetrating trauma, displaced rib fractures, deceleration forces, or sudden compression from a crush injury [11].
Clinical manifestations and diagnosis — Tears in the parenchyma of the lung may cause bleeding, or less commonly, an air leak, resulting in hemothorax and/or pneumothorax [12]. Patients typically present with hemoptysis, signs of respiratory distress, and hypotension. Patients with these findings warrant emergency placement of a chest tube and urgent consultation or referral to a surgeon with pediatric expertise for bronchoscopy. The diagnosis is suspected based upon the presence of a hemothorax and blood in the lower airway on bronchoscopy. Confirmation is made by intravenous contrast computed tomography of the chest in stable patients or at operation in unstable patients.
Management — Initial management focuses on evacuation of the pneumo- and hemothorax and blood transfusion to counter blood loss. (See 'Management' above.)
Most pulmonary lacerations resolve with supportive care consisting of chest tube drainage and supplemental oxygen as needed [13,14]. Persistent bleeding, major air leak, air embolism, massive hemoptysis, or the development of superinfection with abscess formation are indications for surgery.
TRAUMATIC ASPHYXIA — Traumatic asphyxia is a rare consequence of traumatic thoracic or abdominal compression that occurs in children because of the greater flexibility of their thoracic cages [15]. Typically, a marked increase in intrathoracic pressure occurs as the result of direct compression of the chest from crushing injury, in conjunction with deep inspiration against a closed glottis. This increased pressure is transmitted from the right atrium directly through the valveless superior and inferior vena cava, causing rupture of venules and capillaries of the face and head [16]. Thus, traumatic asphyxia has a much different mechanism and clinical presentation than strangulation at the neck. (See "The "choking game" and other strangulation activities in children and adolescents".)
Clinical manifestations and diagnosis — The diagnosis of traumatic asphyxia is based upon clinical findings which include the following [15,17,18]:
●Conjunctival hemorrhages
●Facial edema and cyanosis
●Ecchymotic or petechial hemorrhages on the upper chest and face (picture 1)
Severe cases may manifest any of the following findings [15,17]:
●Hemoptysis
●Bloody discharge from the nose and/or ears
●Exophthalmos
●Vision loss caused by hemorrhage into the retina, vitreous body, or optic nerve
●With prolonged compression, neurologic abnormalities such as altered mental status, brachial plexus injuries, quadriplegia (without evidence of spinal cord injury), and coma [19]
Management — Initial management should focus on support of airway, breathing, and circulation and treatment of related injuries. Interventions to reduce intracranial pressure (such as elevating the head of the bed) may be helpful. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Ongoing management'.)
Although the clinical manifestations of traumatic asphyxia are dramatic, morbidity and mortality are generally related to associated injuries. For children with traumatic asphyxia who survive the initial event, outcomes are generally good [15,18]. The cutaneous findings and subconjunctival hemorrhages typically resolve, and neurologic sequelae are rare.
BLUNT CARDIAC INJURY — Blunt cardiac injury (BCI) is uncommon in children and is most often associated with high energy mechanisms of injury, such as motor vehicle collisions.
Children with BCI often have few presenting signs or symptoms. Thus, diagnosis may be difficult. The presence of any of the following features in the setting of blunt trauma should raise suspicion for BCI:
●Distant or muffled heart tones suggest hemopericardium
●An irregular rhythm may develop as the result of a cardiac contusion
●A new murmur
●Signs of congestive heart failure (eg, gallop rhythm, pulmonary edema, elevated central venous pressure, or hepatomegaly)
The diagnostic approach to pediatric BCI includes:
●Hemodynamically unstable patients with suspected blunt cardiac injury should undergo bedside ultrasound emergently and, if hemopericardium is identified as the cause of the instability, should undergo pericardiocentesis prior to additional diagnostic testing. Patients without hemopericardium should undergo an emergency formal transthoracic echocardiogram to identify any signs of abnormal wall motion or abnormalities of the heart valves or septum.
●Stable patients with findings suggestive of BCI should receive a screening electrocardiogram (ECG), a serum cardiac troponin level, and a chest radiograph, with transthoracic echocardiogram for patients with abnormal diagnostic testing (eg, arrhythmia, bundle branch block, or ST depressions or elevations on ECG; enlarged heart on chest radiograph).
The diagnosis and management of blunt cardiac injury in children is discussed in greater detail separately. (See "Initial evaluation and management of blunt cardiac injury", section on 'Pediatric considerations'.)
TRAUMATIC AORTIC INJURY — Blunt aortic injury (BAI) as the result of thoracic trauma is rare during childhood. Among children with blunt trauma in the United States, the incidence of BAI is <1 percent [20,21]. In a study of nearly 120,000 children <14 years of age with blunt trauma in Israel, only 12 (0.0001 percent) had a thoracic vascular injury of any kind, and seven (0.00005 percent) had an injury to the aorta [22]. It is estimated that among patients of all ages with BAI, 85 percent die at the scene [23].
Clinical manifestations and diagnosis — Clinical features of those who survive and are transported to the emergency department include any of the following [24]:
●Hypotension
●Diminished blood pressure and/or pulses in lower extremities (as compared with upper extremities)
●Paraplegia
However, these findings can be absent among children with BAI, who may demonstrate minimal or no evidence of chest wall trauma [24]. Thus, it is essential to evaluate a chest radiograph in all children who have sustained significant thoracic trauma or a mechanism with forceful deceleration (such as a high-speed motor vehicle collision or fall from a significant height).
Associated injuries that may suggest BAI in children include rib fracture and lung injury (eg, pulmonary contusion, pneumothorax) [25].
The diagnosis of traumatic aortic injury is most commonly made on emergency diagnostic imaging. Children with significant multiple trauma and/or clinical concern for BAI should initially undergo chest radiography. The majority of children with BAI have abnormal chest radiograph (CXR). In some cases, an upright CXR is necessary to determine if the mediastinum is widened or not.
Frequently identified abnormalities include the following [24,26,27]:
●A widened superior mediastinum (image 3)
●A left apical cap (fluid from left mediastinum to the apex)
●An abnormal contour of the aortic knob
●A left hemothorax or pleural effusion (image 4)
Additional imaging is based upon clinical findings, chest radiography, and whether the patient is hemodynamically stable. Stable patients suspected to have BAI typically warrant computed tomography (CT) of the chest with intravenous contrast. It is much more readily available and better tolerated in pediatric patients than transesophageal echocardiogram.
Unstable patients require emergency exploration in the operating room as discussed below.
Management — Emergent consultation with a trauma or cardiothoracic surgeon with pediatric expertise is warranted for any child suspected of BAI based upon physical findings or screening chest radiograph.
●Unstable – Hemodynamically unstable patients should undergo emergent surgical or endovascular repair rather than additional imaging. The use of stenting versus open thoracotomy must weigh the critical issue of the long term impact of growth if stenting is chosen and the patient’s stability for operative repair [28-31]. The optimal approach is best decided by a trauma or cardiothoracic surgeon with pediatric expertise and must take into account institutional capabilities.
●Stable – Hemodynamically stable children typically undergo multidetector CT with intravenous contrast [27,32]. If the enhanced thoracic CT is equivocal, transesophageal echocardiography and/or aortography can also be used to confirm aortic injury. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Aortic injury'.)
Limited evidence among stable adult patients with BAI and without contraindications suggests that control of blood pressure and heart rate with beta blockers prior to operative repair improves survival. However, the role of beta blockers in children is unclear. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Aortic injury'.)
ESOPHAGEAL INJURY — Esophageal injury occurs in 1 percent or less of children with blunt or penetrating thoracic trauma [1,33,34]. Associated injuries are common and may contribute to delay in diagnosis [35]. Mediastinal infection can develop as result of this delay.
Clinical manifestations and diagnosis — The initial symptoms of esophageal rupture can be subtle and nonspecific. Depending upon the region of the esophagus injured, pain may occur in the neck, chest, or abdomen. Thoracic esophageal perforations often cause retrosternal chest pain that radiates to the neck or shoulders.
Early signs of esophageal rupture include tachycardia, dyspnea, abdominal guarding, and subcutaneous emphysema [11,36].
Plain radiographs of the neck and chest may demonstrate retroesophageal air, pneumothorax, pneumomediastinum, pleural effusion, or subcutaneous emphysema [11]. However, plain radiographs are normal in 12 to 25 percent of cases [37]. Furthermore, isolated pneumomediastinum without other thoracic injuries may not be a strong indicator of esophageal injury [38].
Thus, the diagnosis of esophageal injury generally requires esophagography and/or esophagoscopy [11]. In one retrospective series describing the use of flexible esophagoscopy for patients with penetrating esophageal injury, flexible esophagoscopy safely identified all injuries [39].
Management — Children with esophageal perforation should receive fluid resuscitation and administration of broad-spectrum antibiotics to cover gram-positive, gram-negative, and anaerobic organisms (eg, piperacillin/tazobactam or, for patients with penicillin allergy, clindamycin and gentamicin).
Esophageal injuries with ongoing leakage should be repaired as soon as possible, because delay in repair results in increased mortality [40]. Mortality associated with esophageal injuries occurs in up to 43 percent of patients [1]. Small perforations without ongoing leakage on esophagography may be successfully managed nonoperatively.
TRACHEOBRONCHIAL INJURY — Tracheobronchial injuries are rare, occurring in less than 3 percent of children with thoracic trauma [35]. They are associated with high energy mechanisms of injury include motor vehicle collisions, falls from height, and crush injuries. Associated injuries are common [41].
Clinical manifestations and diagnosis — Although many patients die at the scene, children may initially present with mild symptoms such as shortness of breath and cough [42]. Subcutaneous emphysema and stridor may be noted [41-43]. Because children have flexible thoracic cages, they may have tracheobronchial injuries without chest wall injuries. Unlike adults, only 25 percent of children with these injuries also have rib fractures [35]. A tracheobronchial injury should be clinically suspected if a persistent high volume air leak develops after thoracostomy tube placement to relieve a pneumothorax.
Radiographic signs that suggest major airway injury include air within soft tissues or surrounding a bronchus, pneumothorax, hyoid bone elevation (indicating tracheal transection), and obstruction of an air-filled bronchus [44,45]. Computed tomography of the chest confirms the diagnosis and identifies associated injuries [11,46].
Management — Management of tracheobronchial injuries includes airway stabilization and bronchoscopy to identify the injury. Whenever possible, endotracheal intubation should be performed in the operating room with bronchoscopic guidance to avoid worsening of partial tears [11]. All patients who have significant penetrating tracheal injury warrant esophagoscopy to evaluate for esophageal injury. (See 'Esophageal injury' above.)
Patients who have bronchial injuries usually require thoracotomy with bronchial resection and anastomosis, although some children with small tears have been successfully managed nonoperatively [43]. Close follow-up of all patients is necessary to detect complications that should be repaired or for the later development of a stricture.
Approximately one-third of patients with tracheal injuries die, 50 percent of these within the first hour after injury [35]. Airway compromise is the primary cause of death in these patients, who usually have multisystem trauma. Patients who have injuries distal to the trachea may have sequelae that include bronchial stenosis, bronchopleural fistulas, or infection.
DIAPHRAGMATIC INJURY — Diaphragmatic injury may occur as the result of thoracic or abdominal trauma. In a retrospective series describing thoracic and abdominal injuries reported to the National Pediatric Trauma Registry, 4 percent of children had diaphragmatic injuries [1]. Penetrating mechanisms are frequently involved [1,47]. Delay in diagnosis is common [48-50]. Associated injuries (such as pulmonary contusion and hepatic or splenic lacerations) occur in up to 75 percent of patients [47,51,52].
Clinical manifestations and diagnosis — At initial presentation, the patient may have chest pain radiating to the shoulder, shortness of breath, or abdominal pain. Children may have greater respiratory distress than adults because they have a tendency to swallow air when they are stressed, resulting in dilation of the herniated stomach in the setting of left-sided diaphragmatic injuries [47].
Physical findings suggesting the diagnosis of diaphragmatic rupture include auscultation of bowel sounds in the chest, diminished breath sounds on the side of the injury, and scaphoid abdomen [47,53]. Children with diaphragmatic injuries may have no external signs of injury [47].
Chest radiographs may demonstrate bowel gas or loops of intestine above the diaphragm (image 5), the presence of the tip of the nasogastric tube above the diaphragm, or elevated or obscured hemidiaphragm [51,54,55]. Additional nonspecific findings include small mediastinal shifts, lower lobe atelectasis, unilateral pleural effusion, air-fluid levels in the basal lung fields, lower thoracic rib fractures, and pneumothorax or hemothorax. Computed tomography with contrast and upper and lower gastrointestinal series confirm the diagnosis.
The following characteristics of diaphragmatic injuries have been noted:
●Diaphragmatic injury classically occurs with a left-sided predominance because of the protective effect of the liver. The distribution is more equal among patients with severe trauma [50,54].
●The diaphragmatic tears that follow blunt trauma to the chest typically are larger than those that occur with penetrating trauma.
●Penetrating injuries to the diaphragm have been described as high as the third intercostal space and as low as the 12th rib, depending on the phase of respiration at the time of injury [51,56].
Management — The initial management for patients with diaphragmatic injuries includes resuscitation and stabilization of associated injuries. Nasogastric tube placement often is important to reduce stomach size and permit better lung expansion prior to operative repair.
Chest tube placement should be avoided. Herniated abdominal organs can be damaged when a tube thoracostomy is performed in the hemithorax of an undiagnosed diaphragmatic injury. Consequently, a finger should be inserted through the chest wall incision and the diaphragm palpated before the tube is placed, whenever diaphragmatic injury is suspected [11].
Most diaphragmatic defects require operative repair. However, this procedure may be deferred in children with multiple injuries until more urgent diagnostic and therapeutic measures are performed [57,58].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric trauma".)
SUMMARY AND RECOMMENDATIONS
●Thoracic trauma is a marker for severe injury because thoracic injury typically occurs as the result of forceful mechanisms that also cause serious associated injuries. The following injuries may occur as the result of blunt or penetrating thoracic injury in children:
•Pneumo- and hemothorax – Pneumo- and hemothorax often occur together, and each may be life threatening. Physical examination typically demonstrates tachypnea, hypoxemia, respiratory distress, crepitus in the neck and/or chest, chest wall ecchymosis, diminished breath sounds on the affected side, and/or hyperresonance to percussion. In addition to these signs, tension pneumothorax, when present, leads to marked hypotension, distended neck veins, and tracheal deviation away from the affected lung. The diagnosis of pneumo- or hemothorax is suspected based upon clinical findings and is confirmed by evidence of decompression during chest tube placement or needle thoracostomy. In unstable patients, imaging should not delay emergency treatment. Stable pediatric patients may undergo imaging (chest radiograph or bedside ultrasonography) to confirm the diagnosis. (See 'Pneumo- and hemothorax' above.)
•Pulmonary contusion – Pulmonary contusion is defined as pulmonary parenchymal damage with edema and hemorrhage, in the absence of a large pulmonary vessel laceration. Physical examination findings of pulmonary contusion may include chest wall ecchymosis, rales, rhonchi, or decreased breath sounds, but the examination is frequently normal in affected children. Chest radiography typically shows pulmonary consolidation in the region of impact (image 2). (See "Pulmonary contusion in children" and "Pulmonary contusion in children", section on 'Clinical features' and "Pulmonary contusion in children", section on 'Management'.)
•Pulmonary laceration – Tears in the parenchyma of the lung may cause bleeding, or less commonly, an air leak, resulting in hemothorax and/or pneumothorax. Patients typically present with hemoptysis, signs of respiratory distress, and hypotension. Pulmonary laceration can cause exsanguinating hemorrhage, requiring transfusion, particularly after placement of tube thoracostomy. (See 'Pulmonary laceration' above.)
•Traumatic asphyxia – Traumatic asphyxia is a rare consequence of thoracic trauma that occurs in children because of the greater flexibility of their thoracic cages. Dramatic physical findings include conjunctival hemorrhages (picture 1), facial edema, and cyanosis. (See 'Traumatic asphyxia' above.)
•Blunt cardiac injury – Children with blunt cardiac injuries (BCI) may have arrhythmias, new murmurs, heart failure, or hypotension. (See 'Blunt cardiac injury' above.)
•Traumatic aortic injury – Clinical manifestations of traumatic aortic injury include hypotension, diminished blood pressure and/or pulses in lower extremities (as compared with upper extremities), or paraplegia. The diagnosis is also suggested by a widened mediastinum on chest radiograph (image 4). Emergency consultation with a trauma or cardiothoracic surgeon with pediatric expertise is warranted for any child suspected of BAI based upon physical findings or screening chest radiograph. The approach to diagnosis and treatment of children with suspected blunt aortic injury (BAI). Hemodynamically unstable patients should undergo emergency surgical or endovascular repair rather than additional imaging. (See 'Traumatic aortic injury' above.)
•Esophageal injury – Esophageal injuries may be overlooked during the initial evaluation. The initial symptoms of esophageal rupture can be subtle and nonspecific. Pain, which may be retrosternal or radiate to the neck or shoulders, is often reported. Early signs of esophageal rupture include tachycardia, dyspnea, abdominal guarding, and subcutaneous emphysema. (See 'Clinical manifestations and diagnosis' above.)
-The diagnosis of esophageal injury can generally be made with esophagography and/or esophagoscopy. Children with esophageal perforation should receive fluid resuscitation and administration of broad-spectrum antibiotics to cover gram-positive, gram-negative, and anaerobic organisms followed by urgent surgical repair. (See 'Clinical manifestations and diagnosis' above and 'Management' above.)
•Tracheobronchial injury – Children with stridor, subcutaneous emphysema, or a persistent air leak after tube thoracostomy may have tracheobronchial injury. Chest radiograph and chest computed tomography help to confirm the diagnosis. Patients with suspected tracheobronchial injury should be intubated in a controlled situation with bronchoscopic guidance, whenever possible. Surgical repair is usually required. (See 'Clinical manifestations and diagnosis' above and 'Management' above.)
•Diaphragmatic injury – Diaphragmatic injury may not be recognized during the initial evaluation of children with thoracic or abdominal trauma. Chest radiographs may demonstrate bowel gas or loops of intestine above the diaphragm (usually on the left) (image 5), the presence of the tip of the nasogastric tube above the diaphragm, or elevated or obscured hemidiaphragm. The initial management for patients with diaphragmatic injuries includes resuscitation and stabilization of associated injuries. Nasogastric tube placement often is important to reduce stomach size and permit better lung expansion prior to operative repair. Chest tube placement should be avoided. (See 'Diaphragmatic injury' above.)
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
