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Pediatric Chest Tubes and Pigtails November 2015 Pediatric Chest Tubes And Volume 12, Number 11 Authors Pigtails: An Evidence-Based Jonathan Strutt, MD Pediatric Emergency Department, Children’s Hospital and Clinics of Minnesota, Minneapolis, MN Approach To The Management Anupam Kharbanda, MD, MSc Research Director, Associate Fellowship Director, Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Of Pleural Space Diseases Minnesota, Minneapolis, MN Peer Reviewers Abstract Jennifer Mitzman, MD Assistant Professor of Emergency Medicine, The Ohio State Pediatric thoracostomy procedures are used in the emergency depart- University Wexner Medical Center; Assistant Professor of Pediatrics, Nationwide Children’s Hospital, Columbus, OH ment to treat diseases of the pleural space. As children have unique Emily Rose, MD, FAAP, FAAEM, FACEP thoracic anatomy and physiology, they may present with manage- Assistant Professor of Clinical Emergency Medicine, Keck School of ment challenges that the emergency clinician must consider. This Medicine of the University of Southern California, LA County + USC Medical Center, Los Angeles, CA issue reviews the use of chest tubes and pigtail catheters in pediatric CME Objectives patients, techniques and indications for placement, and possible complications. Diagnostic and treatment options for diseases of the Upon completion of this article, you should be able to: 1. Diagnose pleural space disease based on signs and pleural space, such as spontaneous pneumothorax, traumatic injury, symptoms. and parapneumonic effusions/empyema, are examined. Addition- 2. Choose the most effective imaging studies to aid in diagnosis. 3. Determine the types of procedural interventions necessary in ally, this issue discusses the use of imaging modalities to aid in the pleural space disease and when they should be performed. diagnosis of pleural space diseases and the emerging practice of 4. Identify which patients can be safely managed as outpatients. ambulatory management in certain cases. Prior to beginning this activity, see “Physician CME Information” on the back page. Editor-in-Chief Ilene Claudius, MD Alson S. Inaba, MD, FAAP Garth Meckler, MD, MSHS AAP Sponsor Associate Professor of Emergency Associate Professor of Pediatrics, Associate Professor of Pediatrics, Adam E. Vella, MD, FAAP Medicine, Keck School of Medicine University of Hawaii at Mãnoa University of British Columbia; Martin I. Herman, MD, FAAP, FACEP Associate Professor of Emergency of USC, Los Angeles, CA John A. Burns School of Medicine, Division Head, Pediatric Emergency Sacred Heart Children's Hospital, Medicine, Pediatrics, and Medical Division Head of Pediatric Medicine, BC Children's Hospital, Pensacola, FL; Florida State Education, Director Of Pediatric Ari Cohen, MD University School of Medicine, Chief of Pediatric Emergency Medicine Emergency Medicine, Kapiolani Vancouver, BC, Canada Emergency Medicine, Icahn School Medical Center for Women and Pediatric Residency Department, Services, Massachusetts General Joshua Nagler, MD of Medicine at Mount Sinai, New Children, Honolulu, HI Tallahassee, FL York, NY Hospital; Instructor in Pediatrics, Assistant Professor of Pediatrics, Harvard Medical School, Boston, MA Madeline Matar Joseph, MD, FAAP, Harvard Medical School; Fellowship International Editor Associate Editor-in-Chief Director, Division of Emergency Marianne Gausche-Hill, MD, FACEP, FACEP Lara Zibners, MD, FAAP Professor of Emergency Medicine Medicine, Boston Children’s Vincent J. Wang, MD, MHA FAAP Honorary Consultant, Paediatric Associate Professor of Pediatrics, Professor of Clinical Medicine, and Pediatrics, Chief and Medical Hospital, Boston, MA Emergency Medicine, St Mary's Director, Pediatric Emergency Keck School of Medicine of USC; David Geffen School of Medicine James Naprawa, MD Hospital, Imperial College Trust; Associate Division Head, Division at UCLA; Vice Chair and Chief, Medicine Division, University of Associate Clinical Professor EM representative, Steering Group of Emergency Medicine, Children's Division of Pediatric Emergency Florida Medical School-Jacksonville, of Pediatrics, The Ohio State ATLS ®-UK, Royal College of Hospital Los Angeles, Los Angeles, Medicine, Harbor-UCLA Medical Jacksonville, FL University College of Medicine; Surgeons, London, England CA Center, Los Angeles, CA Stephanie Kennebeck, MD Attending Physician, Emergency Associate Professor, University of Department, Nationwide Children’s Pharmacology Editor Michael J. Gerardi, MD, FAAP, Editorial Board Cincinnati Department of Pediatrics, Hospital, Columbus, OH FACEP, President James Damilini, PharmD, MS, BCPS Cincinnati, OH Jeffrey R. Avner, MD, FAAP Associate Professor of Emergency Joshua Rocker, MD Clinical Pharmacy Specialist, Professor of Clinical Pediatrics Medicine, Icahn School of Medicine Anupam Kharbanda, MD, MS Assistant Professor of Emergency Emergency Medicine, St. Joseph's and Chief of Pediatric Emergency at Mount Sinai; Director, Pediatric Research Director, Associate Medicine and Pediatric, Hofstra Hospital and Medical Center, Medicine, Albert Einstein College Emergency Medicine, Goryeb Fellowship Director, Department North Shore-LIJ School of Medicine, Phoenix, AZ of Medicine, Children’s Hospital at Children's Hospital, Morristown of Pediatric Emergency Medicine, Hempstead, NY; Associate Director, Quality Editor Montefiore, Bronx, NY Medical Center, Morristown, NJ Children's Hospitals and Clinics of Division of Pediatric Emergency Minnesota, Minneapolis, MN Medicine, Cohen Children's Medical Steven Choi, MD Steven Bin, MD Sandip Godambe, MD, PhD Associate Clinical Professor Center, New Hyde Park, NY Medical Director of Quality, Director Vice President, Quality & Patient Tommy Y. Kim, MD, FAAP, FACEP of Pediatric Cardiac Inpatient of Emergency Medicine and Safety, Professor of Pediatrics and Associate Director of Emergency Steven Rogers, MD Pediatrics, UCSF School of Services, The Children’s Hospital at Emergency Medicine, Attending Medicine and Pediatrics, Loma Assistant Professor, University of Montefiore; Associate Vice President, Medicine; Medical Director, Division Physician, Children's Hospital of the Linda University Medical Center and Connecticut School of Medicine, of Pediatric Emergency Medicine, Montefiore Network Performance King's Daughters Health System, Children’s Hospital, Loma Linda, CA Attending Emergency Medicine Improvement; Assistant Professor of UCSF Benioff Children's Hospital, Norfolk, VA Physician, Connecticut Children's Melissa Langhan, MD, MHS Pediatrics, Albert Einstein College of San Francisco, CA Medical Center, Hartford, CT Ran D. Goldman, MD Associate Professor of Pediatrics, Medicine, Bronx, NY Richard M. Cantor, MD, FAAP, Professor, Department of Pediatrics, Fellowship Director, Director of Christopher Strother, MD FACEP University of British Columbia; Education, Pediatric Emergency Assistant Professor, Emergency CME Editor Professor of Emergency Medicine Co-Lead, Division of Translational Medicine, Yale School of Medicine, Medicine, Pediatrics, and Medical Deborah R. Liu, MD and Pediatrics, Director, Pediatric Therapeutics; Research Director, New Haven, CT Education; Director, Undergraduate Assistant Professor of Pediatrics, Emergency Department, Medical Pediatric Emergency Medicine, BC and Emergency Department Robert Luten, MD Keck School of Medicine of USC; Director, Central New York Poison Children's Hospital, Vancouver, BC, Simulation; Icahn School of Medicine Professor, Pediatrics and Division of Emergency Medicine, Control Center, Golisano Children's Canada at Mount Sinai, New York, NY Children's Hospital Los Angeles, Hospital, Syracuse, NY Emergency Medicine, University of Florida, Jacksonville, FL Los Angeles, CA Case Presentations department (ED). However, providing immediate in- terventional support for life-threatening problems of A 4-year-old boy is brought in via EMS after a high- the pleural space is an essential skill for all emergency speed motor vehicle crash in which he was an unre- clinicians. Diseases of the pleural space include col- strained rear-seat passenger. His vital signs are: blood lections of air (spontaneous, traumatic, or secondary pressure, 90/59 mm Hg; heart rate, 135 beats/min; pneumothorax), fluid (effusion, chyle, or blood), or respiratory rate, 30 breaths/min; and oxygen saturation, pus (empyema). Many different management strate- 96% on room air. He is awake, but displays signs of gies can be used for diseases of the pleural space, altered mental status. He is maintaining his airway, has including conservative management, needle thoracos- equal bilateral breath sounds, and has strong peripheral tomy, catheter thoracostomy, tube thoracostomy, and pulses. He has contusions on his face and abdomen, with video-assisted thoracoscopic surgery. The focus of this an obvious right femur deformity. After 2 intravenous issue is on the use of chest tubes (tube thoracostomy) lines are placed, a supine chest x-ray is performed, which and pigtails (catheter thoracostomy). The existing is read as normal. You accompany him for a head CT literature was reviewed to develop a strategy for the scan that reveals a small frontal subdural hematoma. emergency clinician that will guide in the diagnosis CT scans of the neck, chest, abdomen, and pelvis are and management of diseases of the pleural space. performed and reveal a left anterolateral pneumothorax. As he returns from the CT scanner, his mental status Critical Appraisal Of The Literature declines and he is emergently intubated to
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