Pediatric emergency medicine trisk 3702 3702

Initial treatment for pneumothorax may consist of observation alone, placement
of a chest tube, or needle thoracentesis. Tension pneumothorax, however, should
always be treated with immediate needle decompression. This is performed by
insertion of a large-bore intravenous (IV) catheter in the midclavicular second
intercostal space of the ipsilateral side, or in the fourth or fifth intercostal space in
the anterior axillary line. If there is a tension pneumothorax, an immediate release
of air should be noted. Evacuation can be facilitated by attaching the catheter to a
two-way stopcock and 60-cc syringe, allowing air to be continuously pulled from
the pleural space although the placement of the catheter alone should temporarily
resolve the tension physiology until tube thoracostomy can be performed. When
using a stopcock and syringe, care must be taken to avoid leaving the stopcock in
place but closed after evacuation of air to prevent recurrence of pleural air and
potentially tension physiology.
Chest Tube
Tube thoracostomy is indicated in the symptomatic patient with pneumothorax or
those requiring air transport. Management of asymptomatic pneumothoraces
identified on CT but not visible on plain radiograph is controversial, but tube
thoracostomy does not appear to be required, even in patients undergoing positive
pressure ventilation.
Tube thoracostomy should be done in the midaxillary line at the level of the
fifth intercostal space (nipple level). If the pneumothorax is not relieved and a
significant air leak continues after chest tube placement, a tracheobronchial
rupture must be considered. Evidence suggests that for a simple pneumothorax,
placement of a pigtail catheter instead of a chest tube has similar efficacy while
causing less pain to the patient. While data in children are lacking, pigtail catheter
placement is often preferred to surgical tube thoracostomy for management of
pneumothoraces due to less need for procedural sedation and postprocedural pain
medication.
Tube thoracostomy, and not pigtail catheter placement, is the treatment of
choice in patients with a hemothorax in order to evacuate blood from the pleural
cavity, reexpand the lung, and prevent or treat any mediastinal shift. Many

hemothoraces may actually represent hemopneumothoraces. As with a
pneumothorax, the chest tube is placed in the midaxillary line at the level of the
fifth intercostal space (nipple level). Patients should be typed and crossed for
packed red blood cells and adequately volume resuscitated, preferably with two
large IV lines in place. For larger hemothoraces, donor blood should be at the
patient’s bedside prior to tube thoracostomy if time permits. After placement of a