Pediatric emergency medicine trisk 4086 4086
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (71.4 KB, 1 trang )
prolonged observation alone, either in the ED or through admission to the
hospital. Pediatric patients with a pneumothorax require observation, even if no
chest tube is believed necessary, to monitor for signs of clinical deterioration
(e.g., hypoxia) and to repeat a chest radiograph as clinically indicated to ensure
no progression of the process. Limited evidence suggests supplemental oxygen
may hasten the rate of pleural air absorption; patients with moderate to large
pleural effusions are typically placed on a nonrebreathing facemask.
Patients with larger pneumothoraces, any hypoxemia or respiratory distress, or
those with evidence of ongoing leak from the lung surface usually require
intervention. Options include thoracentesis, placement of a small “pigtail”
catheter, or placement of a standard chest tube (see Chapter 130 Procedures ). In
the ED, the percutaneous “pigtail” catheters are ideal for pneumothoraces without
associated hemothorax or empyema. However, these catheter devices are small
gauge and may develop fibrin plugs. Therefore, in a patient in whom continuous
accumulation of air takes place in the pleural space despite the presence of a
thoracentesis or pigtail catheter, a standard-sized chest tube should be placed. A
surgical consultation is generally warranted for any patient with a pneumothorax,
particularly if there is evidence of a continuing air leak or the mechanism was
traumatic, or due to an underlying anatomic abnormality.
Tension pneumothoraces are a life-threatening emergency and deserve special
consideration. A tension pneumothorax should be clinically obvious from absent
breath sounds on the affected side, respiratory distress, hypoxia, and tracheal
deviation. These patients require immediate decompression with a large-bore (14gauge) angiocatheter into the second intercostal space anteriorly to evacuate the
air and relieve the tension. Treatment should not be delayed to obtain a chest
radiograph. The insertion of the needle and catheter will immediately result in
release of the tension on the mediastinum and diaphragm. This maneuver should
be followed by the controlled placement of an appropriate-sized chest tube.
Depending on the suspected etiology, further studies such as CT may be
indicated.
Definitive surgical therapy, such as VATS with pleurodesis, is typically
reserved for patients who have recurrent spontaneous pneumothoraces, severe
underlying lung disease, or a persistent air leak not responding to conventional
chest tube drainage. Unfortunately, at least half of children who suffer from a
spontaneous pneumothorax will have a recurrence.
Pneumomediastinum
Pneumomediastinum occurs when there is an abnormal collection of air in the
mediastinum from either a spontaneous or traumatic mechanism. As with
