intercostal arteries may lead to bleeding and a winged scapula. Injury to the intercostal nerve results in continued pain or numbness at the thoracostomy site.
Chapter 168 Thoracostomy Nicole P. Carbonell, MD and Thomas E. Terndrup, MD
Key Points Needle decompression must be performed immediately for suspected tension pneumothorax. Local and systemic anesthesia should be used during insertion of tube thoracostomies. Complications from tube thoracostomy can be minimized by following appropriate technique, including sterility, attention to anatomic landmarks, and confirmation by radiography following placement.
A hemothorax, or blood in the pleural cavity, results from intrathoracic hemorrhage from lacerated lung parenchyma, the heart, great vessels or their branches, the diaphragm, or intercostal or chest wall vessels. Up to 40% of a patient’s total blood volume may be lost into the pleural cavity.1 A combination of air and blood in the pleural space is a hemopneumothorax. Other abnormal pleural collections requiring tube thoracostomy include chylothorax, pulmonary effusion, and empyema. A chylothorax results from a disruption of the thoracic duct. An effusion is fluid in the pleural cavity, and an empyema is a purulent collection. Pulmonary effusions can often be treated with thoracentesis alone, but the presence of an empyema necessitates tube thoracostomy. Indications
Indications and Contraindications Abnormal Pleural Collections Tube thoracostomy is a bedside procedure that allows drainage of a variety of abnormal collections from the thoracic cavity. A pneumothorax is a collection of air in the pleural space. In a simple pneumothorax, air in the pleural space separates the lung and pleura, while a tension pneumothorax results in intrapleural air trapping, potentially causing decreased venous return and shock if sufficiently severe. An open pneumothorax occurs when injury produces a full-thickness chest wall defect that connects the pleural cavity to the body surface. If the chest wall defect has less resistance to airflow than the airways, air preferentially passes in and out of the chest wall defect when the patient takes a breath, interfering with inspiratory airflow. An open pneumothorax with ingress of air is called a “sucking” chest wound. A tension pneumothorax develops when the volume of air trapped in the pleural spaces increases positive intrapleural pressure. Increased intrapleural pressure may shift the mediastinum, compress the vena cava, and lead to decreased cardiac preload, hypotension, shock, and death.1,2 While the most common etiology of tension pneumothorax is secondary to complications from positive pressure ventilation, other causes include bronchial or major parenchymal injury, the inadvertent sealing of a sucking chest wound, or as a complication of a spontaneous pneumothorax. 1194
The significance of these abnormal pleural collections is their interference with respiratory and cardiovascular mechanics. Management depends on several factors, including the etiology and size of the lesion, condition of the patient, need for patient transport, and need for positive pressure ventilation. All tension pneumothoraces are life threatening and should be treated with immediate needle decompression followed by tube thoracostomy. Tube thoracostomy is indicated for any collection that requires continuous drainage over time. Large or symptomatic simple pneumothoraces, open pneumothoraces, recurrent pleural effusions, empyema, and chylothorax should all be managed with tube thoracostomy. Tube thoracostomy may also be indicated in patients with pulmonary contusion or subcutaneous emphysema who undergo prolonged transports, general anesthesia, or positive pressure ventilation, because such patients are at high risk for developing a tension pneumothorax. Less commonly, tube thoracostomy may be used therapeutically for rapid rewarming of pleural structures during intensive management of severe hypothermia, for thoracoscopy to evaluate pleural lesions, or for instillation of agents used to promote scarring or healing of recurrent pneumothoraces. For the hemothorax, tube thoracostomy drains blood that may interfere with respiratory mechanics and may serve as a nidus of infection. It also allows precision measurement of blood loss, monitors the rate of hemorrhage, and helps to prevent organization of the hematoma into a fibrothorax.2 Aggressive fluid resuscitation and administration of blood products are important for patients with massive hemo-
Chapter 168 — Thoracostomy
thorax before significant evacuation is begun. An existing hemothorax may tamponade a briskly bleeding vessel, and clinically significant hypotension may result if the tube thoracostomy is performed before volume resuscitation.3,4 An initial amount of blood drainage of 15 ml/kg or subsequent drainage of 3 to 4 ml/kg/hr for 4 hours is an indication for open thoracotomy.5 Commercial devices exist to collect, fi lter, anticoagulate, and autotransfuse blood drained by tube thoracostomy. An open pneumothorax is managed fi rst with occlusion of the chest wall defect with a three-sided dressing, followed rapidly by tube thoracostomy at an alternate site. The dressing creates a flutter-type valve that prevents air entry during inspiration, but allows trapped air to escape during expiration. Tube thoracostomy followed by repair of the chest wall defect is the treatment of an open pneumothorax. Contraindications There are no absolute contraindications to tube thoracostomy. Relative contraindications include a local dermatologic disorder or a coagulopathy. The site of chest tube insertion can be modified to avoid a problematic skin lesion. Coagulopathies should be corrected, but life-saving procedures should not be withheld. Other relative contraindications include multiple adhesions or blebs, recurrent pneumothoraces mandating surgical treatment, massive hemothorax without adequate volume replacement, or the need for an immediate open thoracotomy. It is widely recommended that a chest tube not be inserted at the site of a penetrating chest wound.
Preparation and Consent Anatomy and Physiology The anatomy and physiology of an infant’s or child’s thorax affects the pathophysiology and management of abnormal pleural collections. A child’s chest wall is less ossified and much more elastic than that of an adult, thus rib fractures are uncommon and severe chest injury may be masked by the absence of external clinical findings. Other intrathoracic injuries, such as pulmonary contusions, occur frequently. A child’s mediastinum is also more mobile, thus mediastinal shift with resultant tracheal and caval angulation is more common in a child.1,2,6,7 The shorter, smaller diameter, and more compressible trachea worsens the potential pathophysiologic consequences of small airway and chest wall injuries.2 Finally, the distal airways are relatively narrow, which creates increased peripheral airway resistance. Greater positive airway pressures required for mechanical ventilation in children also increase the risk of iatrogenic barotrauma. Neonates seem to have the greatest incidence of spontaneous pneumothorax, probably due to the dramatic changes in pulmonary physiology that occur during and immediately after birth.8 Mechanical obstruction of alveoli can occur in the setting of meconium aspiration. Compression of the chest wall in the birth canal puts the respiratory muscles at a mechanical disadvantage. With the first extrauterine breath, the transpulmonary pressure rises from 40 cm H2O to as much as 100 cm H2O. Transmission of this increased pressure to alveoli can lead to overdistention, rupture of alveoli, and development of a pneumothorax.8-10
1195
History and Physical The history of a child with an abnormal pleural collection should include the details of the incident, the child’s past medical and surgical history, medications, and allergies. Detailed information regarding the mechanism of the trauma and the use of personal protective gear or restraints helps the physician predict the pattern of injury. Nonaccidental trauma, falls, motor vehicle collisions, and other transport-related mechanisms such as roller blades and skateboards account for most of the blunt trauma resulting in thoracic injury. Physical examination findings in patients with pleural collections include increased work of breathing and abnormal or diminished breath sounds. The physical examination in a child is not as predictive of thoracic injury as that of an adult. External signs of chest wall trauma may be absent due to the increased compliance of the thoracic cage. In the setting of a tension pneumothorax, one would expect cyanosis, diminished breath sounds, and hyperresonance on the affected side. Contralateral deviation of the trachea and jugular venous distention are late and uncommon fi ndings in children. The shorter neck and wide transmission of breath sounds across the thorax of the child render abnormal auscultatory findings less obvious. Therefore, the sole presentation of a tension pneumothorax in a child may be respiratory distress followed by overt signs of shock. Diagnostic Evaluation The chest radiograph is the primary screening study in the evaluation of all abnormal pleural collections. In the setting of suspected tension pneumothorax in a severely compromised infant or child, it is inappropriate to delay decompression for chest radiography. It is helpful to divide the collections into traumatic and nontraumatic to direct the diagnostic evaluation. For the noninjured patient without a tension pneumothorax, posteroanterior and lateral radiographs of the chest should be obtained to determine whether the collection contains air or fluid. For infants, anteroposterior (AP) and decubitus radiographs are normally required, and when uncertainty exists about an occult pneumothorax, expiratory chest fi lms or chest computed tomography (CT) may be required. Radiographic signs of a pneumothorax include an asymmetric lucency extending beyond lung markings, sharply outlined mediastinal structures, and a shifted mediastinum.2 If the AP radiograph shows fluid, lateral decubitus radiographs should be obtained. All effusions may require thoracentesis to further delineate whether they are transudative, exudative, or purulent, as well as to provide symptomatic relief when substantial. A chest CT is often helpful when the chest radiograph is completely “whited out” to distinguish whole lung consolidation from a free-flowing or a loculated effusion.11 Disadvantages of a CT scan include increased radiation exposure, cost, the associated risks of sedation, and the possibility that the CT scan may miss a multiloculated collection. Thoracic ultrasound is useful to identify air or fluid in the pleural cavity and to delineate the extent of loculation and organization of the effusion or empyema.11 Such information is very useful in determining whether the collection can be treated at the bedside with tube thoracostomy or whether surgical intervention is necessary. In the setting of trauma, the supine AP chest radiograph is taken early during the secondary survey. In this position,
1196
SECTION VII — Procedures, Sedation, Pain Management, and Devices
air layers anteriorly, and radiographic signs of a pneumothorax may be subtle or absent. Researchers have shown that CT better describes the characteristics and extent of injury than chest radiographs, but is not clear that this extra information changes patient management.12-17 Occult pneumothoraces are often an unexpected finding on an abdominal CT scan of pediatric trauma patients. A prospective study of 538 pediatric trauma patients undergoing both chest radiography and abdominal CT found that 55% of pneumothoraces found on the CT (11 of 20) were not identified on the initial chest radiograph. However, only 1 of the 11 occult pneumothoraces required tube thoracostomy.18 This study validates the notion that the increased information obtained with the CT may not alter patient management, and that not all occult traumatic pneumothoraces require tube thoracostomy. Consent Informed consent for tube thoracostomy in minors should be obtained from parents or the most appropriate legal guardian if available. Emergency consent is implied for lifesaving procedures. Assent by the child is normally required in children age 7 years or older. Pain Management and Sedation Proactive and effective pain management in children should be a priority for all practitioners who care for infants and children. Tube thoracostomy is painful regardless of who is performing the procedure. If the patient is awake, infi ltrative local anesthetic is clinically prudent. Intravenous opioids, dissociative agents, and anxiolytics should be used early in management, with small, titrated doses depending upon the individual needs of the patient.19 Using a small-gauge needle, preferentially 27 or 30 gauge, as well as buffering the lidocaine with bicarbonate, substantially decreases the pain associated with the infi ltration of subcutaneous and local lidocaine anesthetic.
Equipment The contents of a typical prepackaged tube thoracostomy tray are listed in Table 168–1. Other adjunctive supplies include adhesive tape, tincture of benzoin, antiseptic solution, proper-sized chest tubes, and a drainage apparatus with sterile water for water seal, plastic tubing, and connectors. All equipment should be assembled and inspected before beginning the procedure. The size of the chest tubes will vary with the patient’s size and type of collection to be drained. Larger tubes are used to drain blood or pus; smaller tubes drain air (Table 168–2). The appropriate-sized chest tube can
be estimated from the patient’s weight. The clinician should ensure adequate lighting, monitoring equipment, and assistant personnel. Drainage Systems All chest tubes need a fluid drainage system, except for those with flutter valves used periodically for simple pneumothoraces. With the extrathoracic end of the tube placed underwater at a level below the chest, air under positive intrapleural pressure escapes into the bottle and cannot reenter the pleural space. A single bottle system works only for the drainage of air. If fluid is draining in a single-bottle system, it will build up in the bottle, increase pressure of the water seal system, and render it ineffective. A two-bottle system allows fluid to collect in the second bottle while still providing an escape for pressurized intrapleural air. Suction improves the rate of drainage of fluid or air, but can damage the lung parenchyma or pleura if applied directly to the system. Adding a third bottle to the two-bottle system connected to the water seal bottle and fi lled to a level corresponding to the desired level of suction (usually 15 to 20 cm H2O) avoids this problem. The vent allows the entrance of air from the environment when the wall suction applied is greater than the set level. Commercially available plastic chest tube drainage units usually employ the three-bottle system (Fig. 168–1). Table 168–2 Patient Age Premature 0–6 mo 6–12 mo 1–3 yr 4–7 yr 8–10 yr
Determination of Appropriate Chest Tube Size by Patient Age and Weight Weight (kg)
Tube Size (French)
3 3.5 7 10–12 16–18 24–30
10–14 12–18 14–20 14–24 20–32 28–38
From Extremes of trauma: Pediatric trauma. In American College of Surgeons Advanced Trauma Life Support For Doctors: Student Course Manual, 7th ed. Chicago: American College of Surgeons, 2004, pp 243–262.
Pleural cavity
To suction
Vent
Collection Water seal
Table 168–1
Contents of a Typical Tube Thoracostomy Tray
Sterile gauze Kelly clamps Large suture and Mayo scissors Local anesthetic Multiple syringes and needles Needle driver No. 0 silk sutures Scalpel Sterile towels
15-20 cm Suction control
FIGURE 168–1. Commercial three-bottle system. (From Connors KM, Terndrup TE: Tube thoracostomy and needle decompression of the chest. In Henretig FM, King C [eds]: Textbook of Pediatric Emergency Procedures. Baltimore: Williams & Wilkins, 1997, p 404.)
Chapter 168 — Thoracostomy
Monitoring Patients with chest tubes need continuous cardiac and pulse oximetry monitoring. Once analgesia or sedation is administered, continuous monitoring for efficacy and complications is necessary. Routine assessment of respiratory rate and effort, arterial blood pressure, and level of consciousness is performed, and oxygen is monitored continuously. Guidelines promulgated by the American College of Emergency Physicians and American Academy of Pediatrics should be incorporated into institutional guidelines for monitoring during tube thoracostomy (see Chapter 159, Procedural Sedation and Analgesia).
Technique Needle Decompression Needle decompression is the first step for the direct treatment of a tension pneumothorax. Endotracheal intubation and positive pressure ventilation in severely ill patients with an undiagnosed pneumothorax may worsen the patient’s condition, and immediate decompression is required. The patient is positioned in supine with the head of the bed elevated 30 degrees. The insertion site is swabbed with antiseptic, and a local infi ltrative anesthetic is used if time permits. A largegauge needle or angiocatheter is inserted perpendicularly over the superior aspect of the third rib, and walked over the rib into the lower portion of the second intercostal space at the midclavicular line (Fig. 168–2). A rush of air is usually heard or felt as the pleural space is entered and pressurized air is evacuated. When using an angiocatheter, it should be
Second intercostal space midclavicular line
Third, fourth, or fifth intercostal space anterior midaxillary line FIGURE 168–2. Sites of needle decompression and tube thoracostomy. (From Connors KM, Terndrup TE: Tube thoracostomy and needle decompression of the chest. In Henretig FM, King C [eds]: Textbook of Pediatric Emergency Procedures. Baltimore: Williams & Wilkins, 1997, p 399.)
1197
advanced into the pleural space, then the needle is removed and the catheter left in place. Tube Thoracostomy The patient is positioned in supine with the head of the bed elevated 30 degrees. The preferred insertion site is the fourth or fifth intercostal space at the anterior or midaxillary line20-22 (see Fig. 168–2). Using universal precautions, the insertion site is prepared and sterilely draped. A generous wheal of local anesthetic is made over the rib below the insertion site, anesthetizing the subcutaneous tissue overlying the upper rib, the periosteum, and the pleura. To anesthetize the pleura, the needle is advanced into the pleural space where air or fluid can easily be aspirated. Then, it is withdrawn slowly while aspirating until no air or fluid returns. At this point, injected lidocaine should anesthetize the pleura. Caution should be used not to exceed 5 mg/kg of total lidocaine to avoid systemic toxicity. An incision is made with a scalpel through the skin and subcutaneous tissue at the site of the skin wheal. In an infant or a small child, a 0.5- to 1-cm incision will be adequate, while in a larger child or adolescent, a 2- to 4-cm incision may be necessary. Next, blunt dissection is performed through the subcutaneous tissue by opening and closing a Kelly clamp. Tunneling over the next rib provides a better seal against air leaks while the tube is in place, and may help to prevent pleural fistulas when it is removed. Dissection is continued to the upper surface of the upper rib, avoiding the neurovascular structures located on the inferior margin of the rib. Next, the tip of the clamp is slid over the superior rib margin through the intercostal muscles and parietal pleura with firm but controlled pressure. A “pop” or sudden loss of resistance and a rush of air or fluid should be felt when the pleural is punctured. The tip of the clamp is placed 1 cm into the thoracic cavity and spread widely to open the pleura. The clamp is then withdrawn and the pleural space checked with a finger to confirm placement and strip any adhesions between the lung and parietal pleura. The chest tube is guided into the pleural space with the finger or with a Kelly clamp inserted through the tip of the chest tube. If the patient is large, the probing finger is left in the pleural space and the tube is guided along the track of the finger while attached to a curved clamp (Fig. 168–3). For a fluid collection, the chest tube is directed posteriorly and superiorly. For pneumothorax alone, it is directed anteriorly and superiorly. It is critical to insert the chest tube far enough that all the side holes lie within the pleural space. The tube is connected to a drainage system, and secured with a suture. A purse-string type suture placed around the chest tube where it enters the chest wall secures the tube and closes the incision when the tube is removed After suturing, an occlusive dressing with petrolatum gauze is placed around the base of the tube as it enters the skin. This is covered with two pieces of gauze that are each cut from the middle of one side to the center and oriented 90 degrees to each other. Then the area and the tube are securely taped down. Chest tube placement should be verified by a chest radiograph as soon as possible. Serial radiographs confirm the resolution of the collection. Any sudden change in the patient’s cardiorespiratory status should be considered to be a recurrence of the collection until proven otherwise. Patients receiving mechanical ventilation are especially at risk for
1198
SECTION VII — Procedures, Sedation, Pain Management, and Devices
5
5
Tunneling one interspace above skin incision avoiding neurovascular bundle Parietal pleura
Pulmonary pleura 6
Lung
6
Skin incision
A
6
B
C 5
D 6
Chest tube grasped with clamp
Horizontal mattress secured
E
F
G
FIGURE 168–3. Blunt dissection technique. A, Incision made one interspace below proposed site of insertion. B, Blunt dissection throughout the subcutaneous tissue. C, Clamp spread after entering the pleural space. D, Probing finger confirms placement, identifies the diaphragm, and strips adhesions. E and F, Chest tube grasped with clamp and inserted. G, Chest tube sutured securely in place. (From Connors TM, Terndrup TE: Tube thoracostomy and needle decompression of the chest. In Henretig FM, King C [eds]: Textbook of Pediatric Emergency Procedures. Baltimore: Williams & Wilkins, 1997, p 401.)
recurrence of the original collection or the development of a new pneumothorax.
Alternatives Conservative Management Children with a simple, iatrogenic, or occult traumatic pneumothorax are often asymptomatic.23,24 A few studies suggest that conservative management may be safe in children.18 Observation alone is appropriate when the patient is other-
wise healthy, the pneumothorax is unilateral and small, and the patient is not likely to require positive pressure ventilation, general anesthesia, or a lengthy transport. Patients managed conservatively require an observation period. While normal pleural blood flow reabsorbs the air at about 1.25% per day, supplemental oxygen increases the rate of absorption by as much as sixfold.25 Therefore, the patient should be placed on a pure oxygen mask or nasal oxygen immediately and continuously until the appropriate end point is reached. Serial radiography monitors the progression of the collection. Estimating the size of a pneumothorax is often
Chapter 168 — Thoracostomy
inaccurate, but most authorities agree that a small pneumothorax occupies less than 10% to 20% of the thoracic cavity.20,26 Catheter Aspiration Larger, simple spontaneous or iatrogenic pneumothoraces may be managed by catheter aspiration. Catheter aspiration has several advantages over tube thoracostomy. It is simpler to perform, less traumatic, leaves a smaller scar, and generally results in less patient discomfort.25,27,28 Trauma patients with a tension pneumothorax, hemothorax, persistent air leak, hemodynamic instability, or other serious injuries are not candidates for this procedure. Underlying lung pathology (e.g., restrictive or reactive lung diseases) is also a relative contraindication for catheter aspiration.
Complications Patients undergoing tube thoracostomy infrequently have serious complications.29 Complications from incorrect insertion include damage to local anatomic structures, ineffective drainage, and infection. Damage to the thoracic nerve and intercostal arteries may lead to bleeding and a winged scapula. Injury to the intercostal nerve results in continued pain or numbness at the thoracostomy site. Blunt dissection and avoiding the neurovascular bundle on the inferior margin of the rib minimizes the risk of neurovascular injury. Foley catheter tamponade of hemorrhage from a lacerated intercostal artery has been reported in a neonate.30 Other complications include damage to thoracic or abdominal organs. The blunt dissection technique minimizes this risk by providing an easy passage for the tube. Using a finger to explore the tract and pleural space also minimizes the risk of diaphragm penetration or subcutaneous placement. A high-lying diaphragm occurs in the setting of forced expiration, hemidiaphragm paralysis, previous thoracotomy, intra-abdominal injuries, and the supine position. Abdominal placement of a chest tube can occur in this setting.31 If a high-lying diaphragm is suspected, sit the patient upright to reduce the possibility of injury. A chest tube inserted too far presses against the pleura or thoracic structures and causes rare but serious complications. Cardiogenic shock secondary to right atrial compression can occur.32 Horner’s syndrome due to pressure on the inferior cervical ganglion has been reported.33,34 Diaphragm paralysis due to phrenic nerve injury has also been reported.35 A chest tube not inserted far enough for all drainage holes to lie within the pleural cavity increases the risk of an air leak and subcutaneous emphysema. Correcting the position of the chest tube and applying suction under a water seal is the treatment for both air leaks and subcutaneous emphysema.36 Complications can result even with a properly placed tube. The tube itself may move or become disconnected. Re-expansion pulmonary edema and hypotension have been described following drainage of large, long-standing effusions in young patients.25,37 Treatment for re-expansion pulmonary edema is supportive. Finally, significant scarring can occur at the insertion site. Placing a chest tube in the midclavicular line or even too high in the anterior axillary line of premature neonates has resulted in severe breast deformities.38 Lateral placement of the chest tube minimizes the cosmetic impact of scarring.
1199
Finally, infectious complications may occur. Splinting due to pain at the insertion site may lead to pneumonia or atelectasis. Intercostal nerve blocks, intravenous opioids, and use of incentive spirometry help prevent these complications. Infection at the insertion site is minimized by good sterile technique. The role of prophylactic antibiotics for tube thoracostomy is unclear. The adult literature is inconclusive, but one study demonstrated a benefit of fewer infectious complications and a shorter hospital stay resulting from the administration of a first-generation cephalosporin during tube thoracostomy.39 Despite this research, most authorities do not recommend prophylactic antibiotics for tube thoracostomy in children.40
Postprocedure Care and Disposition All patients with a chest tube need admission for observation, serial radiography, and eventual removal of the chest tube following resolution of their injury or illness. The exception to this is the rare case of simple pneumothorax drained with a catheter aspiration and a flutter valve that might be safely managed on an outpatient basis with close follow-up. In the emergency department, patients must be continually monitored for further deterioration from their illness or injury. Ongoing management of hemodynamic, neurologic, respiratory, analgesia-sedation, and other patient care needs must be maintained throughout the course of the patient’s acute clinical problems. REFERENCES 1. Grisoni ER, Volsko TA: Thoracic injuries in children. Respir Care Clin N Am 7:25–38, 2001. 2. Bliss D, Silen M: Pediatric thoracic trauma. Crit Care Med 30(11 Suppl):s409–s415, 2002. 3. Rhea JT, Deluca SA, Greene RE: Determining the size of pneumothorax in the upright patient. Radiology 144:733, 1982. 4. Bayne CG: Pulmonary complications of the McSwain dart. Ann Emerg Med 11:136, 1982. 5. Cullen ML: Pulmonary and respiratory complications of pediatric trauma. Respir Care Clin N Am 7:59–77, 2001. 6. Stafford PW, Blinman TA, Nance ML: Practical points in evaluation and resuscitation of the injured child. Surg Clin North Am 82:273–301, 2002. 7. Beaver BL, Laschinger JC: Pediatric thoracic trauma. Semin Thorac Cardiovasc Surg 4:255–262, 1992. 8. Yu VY, Lieu SW, Robertson NR: Pneumothorax in the newborn: changing patterns. Arch Dis Child 50:449, 1975. 9. Monin P, Vert P: Pneumothorax. Clin Perinatol 5:535, 1978. 10. Wigglesworth JS: Pathology of the lung in the fetus and neonate, with particular reference to problems of growth and maturation. Histopathology 11:671–689, 1987. 11. Lewis RA, Feigin RD: Current issues in the diagnosis and management of pediatric empyema. Semin Pediatr Infect Dis 13:280–288, 2002. 12. Brasel KJ, Stafford RE, Weigelt JA, et al: Treatment of occult pneumothoraces from blunt trauma. J Trauma 46:987–990, 1999. 13. Rhea JT, Noveline RA, Lawrason J, et al: The frequency and significance of thoracic injuries detected on abdominal CT scans of multiple trauma patients. J Trauma 29:502–505, 1989. 14. Hill SL, Edmisten T, Holtzman G, et al: The occult pneumothorax: an increasing entity in trauma. Am Surg 65:254–258, 1999. 15. Sivit CJ, Taylor GA, Eichelberger MR: Chest injury in children with blunt abdominal trauma: evaluation with CT. Radiology 171:815–818, 1989. 16. Bridges KG, Welch G, Silver M, et al: CT detection of occult pneumothorax in multiple trauma patients. J Emerg Med 11:179–186, 1993. 17. Furnival RA: Controversies in pediatric thoracic and abdominal trauma. Clin Pediatr Emerg Med 2:48–62, 2001.
1200
SECTION VII — Procedures, Sedation, Pain Management, and Devices
*18. Holmes JF: A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med 39:492–499, 2002. 19. Murat I, Gall O, Tourniaire B: Procedural pain in children: evidencebased best practice and guidelines. Reg Anesth Pain Med 28:561–572, 2003. *20. Iberti TJ, Stern PM: Chest tube thoracostomy. Crit Care Clin 8:879– 894, 1992. 21. Symbas PN: Chest drainage tubes. Surg Clin North Am 69:41–46, 1989. 22. Miller KS, Sahn SA: Chest tubes: indications, technique, management and complications. Chest 91:258–264, 1987. 23. Collins JC, Levine G, Waxman K: Occult traumatic pneumothorax: immediate tube thoracostomy versus expectant management. Am Surg 58:743–746, 1992. 24. Wolfman NT, Gilpin JW, Bechtold RE, et al: Occult pneumothorax in patients with abdominal trauma: CT studies. J Comput Assist Tomogr 17:56–59, 1993. 25. Baumann MH, Strange C: Treatment of spontaneous pneumothorax: a more aggressive approach? Chest 112:789–804, 1997. 26. Vukick DJ: Diseases of the pleural space. Emerg Med Clin North Am 7:309–324, 1989. 27. Minami H, Saka H, Senda K, et al: Small catheter drainage for spontaneous pneumothorax. Am J Med Sci 304:345–347, 1992.
*Suggested readings.
28. Conces DJ, Tarver RD, Gray WC, et al: Treatment of pneumothoraces utilizing small caliber chest tubes. Chest 94:55–57, 1988. 29. Ernst A: Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians. Chest 123:1693–1717, 2003. 30. McElroy SJ: Foley catheter tamponade of intercostals hemorrhage in preterm infants. J Pediatr 145:241, 2004. 31. Foresti V, Villa A, Casati O, et al: Abdominal placement of tube thoracostomy due to lack of recognition of paralysis of hemidiaphragm. Chest 102:29, 1992. 32. Kolleff MH, Dothager DW: Reversible cardiogenic shock due to chest tube compression of the right ventricle. Chest 99:976–980, 1991. 33. Mahfood S, Hix WR, Aaron BL, et al: Reexpansion pulmonary edema. Ann Thorac Surg 45:340, 1988. 34. Cook T, Kietzman L, Leibold R: “Pneumo-ptosis” in the emergency department. Am J Emerg Med 10:431–434, 1992. 35. Nahum E: Acute diaphragmatic paralysis caused by chest-tube trauma to phrenic nerve. Pediatr Radiol 31:444–446, 2001. 36. Cerfolio RJ: Advances in thoracostomy tube management. Surg Clin North Am 82:833–848, vii, 2002. 37. Bertino RE, Wesbey GE, Johnson R: Horner syndrome occurring as a complication of chest tube placement. Radiology 164:745, 1987. 38. Rainer C, Gardetto A, Fruhwirth M, et al: Breast deformity in adolescence as a result of pneumothorax drainage during neonatal intensive care. Pediatrics 111:80–86, 2003. 39. Gonzales RP, Holevar MR: Role of prophylactic antibiotics for tube thoracostomy in chest trauma. Am Surg 65:617–621, 1998. 40. Mollitt DL: Infection control: avoiding the inevitable. Surg Clin North Am 82:365–378, 2002.
