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Successful pedrformance of a variety of procedures may prove critical in management of patients throughout the pediatric age spectrum. Although the frequency of procedures performed in clinical practice will vary, the physician should feel confident in performance of the procedures, and have knowledge of the indications, contraindications, and alternative procedures. When possible and circumstances allow, obtain appropriate informed consent prior to beginning a procedure. The following procedures are described in detail: tube thoracostomy, cardioversion and defibrillation, cardiac pacing, pericardiocentesis, peripheral intravenous catheter placement, umbilical vessel catheterization, central venous access, venous cutdown, intraosseous access, arterial catheter placement, gastrostomy tube replacement, abscess incision and drainage, external auditory canal foreign body removal, nasal canal foreign body removal, epistaxis management, common dislocation reductions, arthrocentesis, lumbar puncture, and subprapubic bladder catheterization.


Management of a patient’s airway is paramount in the emergency clinical setting. Identification of the patient who may benefit from simple or advanced airway management is not always straightforward. A number of methods and techniques described below may be employed in order to appropriately care for the patient in need of airway interventions. See Chapter 9, Compromised Airway, for further discussion.




Insertion of a tube thoracostomy may be indicated to relieve the accumulation of fluid or air from the pleural space. The patient may require a tube thoracostomy because of trauma, spontaneous pneumothorax, iatrogenic causes, or other systemic disease processes. Parapneumonic effusions may also require placement of a tube thoracostomy to assist in patient management.


Chest tube thoracostomy is often a lifesaving procedure and has few contraindications, which are typically relative, such as coagulopathy or overlying skin infection. The need for lung re-expansion typically takes priority over relative contraindications. There are no alternative procedures for most indications for tube thoracostomy. The clinician should always ensure that the correct side is affected prior to procedure initiation.

Equipment and Supplies

Gather all needed supplies and materials before performing the procedure. Many facilities provide a standardized tube thoracostomy tray with all essential supplies for the procedure; it is prudent to check the supply list on the tray to assure all needed elements are provided. In the absence of a prepackaged tray, determine that the following supplies and equipment are present and ready for use:

  • Skin sterilization supplies

  • Sterile technique operator equipment and personal protective equipment: mask, cap, gown, and sterile gloves

  • Local anesthetic, syringe, and appropriate needles

  • Sterile towels and drape

  • Appropriate chest tube

  • Scalpel, #11 or #15 blade is preferred

  • Kelly and Mayo clamps

  • Size 0 silk suture

  • Needle holder

  • Petrolatum-impregnated gauze

  • Sterile gauze 4-inch squares

  • 2- or 3-inch wide silk or plastic adhesive tape

  • Suction device, typically a commercially available prepackaged ...

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