Chapter 3. Procedures

• 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).

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

Setup

Procedure

• 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.

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