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  • Explain the necessity of the procedure, the steps involved, and the risks.
  • Obtain informed consent, except in life-threatening emergencies.
  • Request a Child Life Specialist.
  • Gather all necessary equipment for the procedure.
  • Consider procedural sedation (see Chapter 2).
  • Consider having a crash cart for any procedures involving airway or sedation.
  • Recruit an assistant and explain what is expected of him or her during the procedure.
  • Perform a “time-out” to ensure the correct patient and the correct site for the procedure.
  • Position the child and provide adequate restraint if required.
  • Carry out the procedure.
  • Document the procedure in the chart (elements: consent, from whom consent was obtained, preparation, anesthesia used, equipment used, site of procedure, outcome of procedure, and any complications).

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  • Indications: (1) Tension pneumothorax
  • Complications: Pneumothorax, bleeding, nerve damage, infection

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Setup

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Equipment Needed for Needle Decompression of Pneumothorax

  • • Personal protection equipment: Gloves, gown, face and eye shield
  • • Pulse oximeter and cardiorespiratory monitor
  • • Oxygen supply via nonrebreather mask
  • • Antiseptic skin prep solution (eg, Povidone-iodine, Chlorhexidine)
  • • Local anesthetics: 1% lidocaine drawn up
  • • 16- to 20-gauge needle or plastic-over-the-needle catheter (IV catheter)
  • • 50-mL syringe with a stopcock
  • • Occlusive dressing (vaseline gauze, 4 × 4 gauzes and tape)
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Procedure

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  • Attach the patient to a cardiorespiratory monitor and apply oxygen per nonrebreather mask.
  • On the affected side, locate the second intercostal space at the midclavicular line.
  • Prep the skin using sterile techniques if patient is stable.
  • If the patient is stable, raise a wheal with 1% lidocaine over the superior edge of the rib below the intercostal space (third rib).
  • Penetrate the skin over the superior edge of the rib using a 16- to 20-gauge IV catheter.
  • Advance the IV catheter gradually until a pop is heard or felt on entry of the pleural space.
  • Remove the needle (a rush of air may be audible as tension is released).
  • Attach a syringe with a stopcock to the hub of the catheter.
  • Withdraw desired air, releasing further tension.
  • Withdraw the needle at the end of the procedure and apply an occlusive dressing to the site (preferably with 3 of 4 sides fixed to skin to create a one-way flap-valve for further decompression).
  • Obtain a CXR to assess the results of the procedure.

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Emergent

Non-emergent

Pneumothorax

  • Large pneumothoraces
  • In all patients on mechanical ventilation
  • Tension pneumothorax after needle decompression
  • Recurrent or persistent pneumothorax
  • Pneumothorax secondary to chest trauma

Hemopneumothorax

Esophageal rupture with gastric leak into the pleural space

Malignant pleural effusion

Recurrent pleural effusion

Treatment with sclerosing agents or pleurodesis

Parapneumonic effusion or empyema

Chylothorax

Postoperative care (eg, after coronary bypass, thoracotomy, or lobectomy)

Reproduced with permission from: NEJM 2007;357:e15.

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  • Complications: Bleeding; hemothorax; perforation of visceral organs (lungs, heart, liver, spleen); ...

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