Chest trauma in children is associated with high morbidity and mortality. Thoracic injuries can lead to respiratory distress, hypoxia and massive hemorrhage. Begin by observing and palpating the chest for asymmetrical or paradoxical chest movement, contusions, penetrating injuries, instability and crepitations. Auscultate the chest for equal bilateral breath sounds and any abnomral sounds, such as wheezing or crackles. Assess heart sounds for rate, rhythm and quality or muffled sounds, suggestive of cardiac tamponade.