Pediatric emergency medicine trisk 4088 4088
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esophageal foreign body or a significant history of forceful emesis, an
esophagram using water-soluble contrast may be helpful. In the extremely rare
case of a tension pneumomediastinum, evacuation of the accumulated air in the
mediastinum is necessary.
FIGURE 124.6 A: Significant pneumomediastinum with accentuation of the cardiac silhouette.
B: A far more subtle pneumomediastinum in an asthmatic patient with chest pain.
Pleural Effusion
Pleural fluid in excess amount is not a disease per se, but it indicates the presence
of pulmonary or systemic illness. The classification of the fluid into transudate ,
which accumulates when the normal pressure relationships between the capillary
pressure in the lung, the pleural pressure, and the lymphatic drainage pressure are
disturbed, or exudate , an inflammatory collection, has less utility today because
of other diagnostic tools presently available. Nevertheless, it is important to
recognize causes of transudative fluid collections, including increased pulmonary
capillary pressure (as in congestive heart failure), decreased colloid osmotic
pressure (as in renal disease), increased intrapleural negative pressure (as in
atelectasis), or impaired lymphatic drainage of the pleural space (e.g., from
surgical trauma to the thoracic duct). In children, the inflammatory cause of
effusion is most commonly a result of pneumonia, with accumulation of infected
fluid in the pleural space, or empyema (see below). Malignant effusions from
associated oncologic diagnoses are much less common than in adults, but also
occur in children. The accumulation of blood in the pleural space because of
trauma is discussed in Chapter 115 Thoracic Trauma . Hemothorax may also
