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or aggressive resuscitation. Pneumothorax is more common in premature infants
with surfactant deficiency or meconium aspiration. If significant respiratory
distress is present and a pneumothorax is suspected, rapid decompression may be
achieved with a large syringe, 20-gauge needle, or catheter over needle using a
three-way stopcock. The needle is advanced at the fourth intercostal space in the
anterior axillary line or the second interspace in the midclavicular line.
Subsequently, a chest tube (8F) may be placed using a standard technique (see
Chapter 130 Procedures ).

Congenital Diaphragmatic Hernia
CDH is a true neonatal emergency; the diagnosis is confirmed by a chest
radiograph showing bowel gas within the thorax ( Fig. 9.19 ). Infants with CDH
require emergent ET intubation to avoid excessive amounts of air accumulation in
the bowel. A nasogastric tube should be rapidly placed to decompress the
stomach. The infant must be rapidly evaluated by a pediatric surgeon after
ventilation is stabilized and venous access is achieved.

TEAMWORK IN RESUSCITATION FOR ALL PEDIATRIC
PATIENTS
Existing resuscitation curricula of the AHA incorporate learning modules on
leadership, role clarity, and communication. Effective leaders and team members
must have cognitive (fund of knowledge), technical and procedural, and
behavioral skills. Postresuscitation team debriefing is increasingly recognized as a
critical component in maintaining effective teamwork and communication skills
in pediatric resuscitations. Recent information reveals lack of effective teamwork
skills and its negative impact on outcomes. Effective education includes
challenging hands-on active exercises, such as role play and high-fidelity
simulation. A formal process for the review of video recordings of resuscitations
provides another avenue for identifying opportunities for improving care
processes and for providing constructive feedback on team management skills.
Maintenance of competency for physicians working in ED settings includes

procedural and leadership competencies. Developing and maintaining the ability
to effectively lead a multidisciplinary team in a high-stakes, high-risk, error-prone
environment is necessary and must be thoughtfully considered in this era of
decreasing frequency of individual exposure to these patients.
Finally, parental presence in the resuscitation room is recommended by the
AAP and should be routine practice. All EDs should have a written policy and a
process in place, and all families should be offered this opportunity for family
presence (see Chapter 7 A General Approach to the Ill or Injured Child ).