A 12-year-old boy is brought in by EMS with a single stab wound to the right lower-anterior chest. He is alert and oriented, but noted to be tachycardic, borderline hypotensive, and agitated. During your primary survey, you note that his airway is intact. Breath sounds on the left are normal, but there is no air movement on the right. There is a small laceration to the right anterior chest. Peripheral pulses are present but thready, and capillary refill is noted to be 4 to 5 seconds. You place the patient on supplemental oxygen and obtain IV access with 2 large-bore lines. The patient begins to decompensate and becomes anxious and combative. His blood pressure is now 62/30 mm Hg. What are the immediate life-threatening conditions you need to consider? What tools do you have at your disposal to make an appropriate diagnosis? As your heart races, you consider the possibility of a tension pneumothorax and life-threatening intrathoracic or intra-abdominal bleeding. Do you place a surgical thoracostomy tube? A pigtail catheter? Transfuse blood? What life-saving maneuvers should you perform immediately?
A 15-year-old boy then presents for evaluation of acute-onset chest pain and shortness of breath. The patient states that he felt sudden, sharp, right-sided chest pain in class an hour ago. The patient denies fever, upper respiratory symptoms, cough, nausea, vomiting, or diarrhea. There is no report of travel or trauma. The patient does report frequent marijuana and cigarette smoking. His vital signs are: heart rate, 94 beats/min; blood pressure, 112/70 mm Hg; respiratory rate, 18 breaths/min; and oxygen saturation, 97% on room air. Lung sounds are slightly diminished on the right. You send the patient for a chest x-ray and begin to consider management options. Are there other aspects of the history you should obtain? Should you order a chest CT to look for blebs or other malformations? Should you order screening labs or place a thoracostomy tube or a pigtail catheter? Should you admit this patient?
A pneumothorax is the pathologic collection of air within the pleural space, which is a potential space between the visceral and pleural lining. A pneumothorax can be the result of a spontaneous perforation of the lung parenchyma, chest wall trauma, disruption of the bronchotracheal tree, or, rarely, it may be iatrogenic in nature. A pneumothorax represents many different disease entities that may vary greatly in severity. Pneumothoraces are classically divided into 2 distinct categories: spontaneous and secondary. Spontaneous pneumothoraces, are idiopathic, without obvious cause. Secondary pneumothoraces occur in the setting of trauma or an underlying condition, or they may be iatrogenically induced in patients after thoracic surgery, placement of a central venous catheter, or intubation.
Most data regarding the management of pneumothorax in the pediatric population are extrapolated from literature that evaluates primarily adult patients, with few papers and no randomized controlled trials evaluating pediatric patients or producing pediatric management guidelines.1 There are no standardized guidelines promoting specific diagnostic modalities or therapeutic interventions for children with pneumothorax; however, early identification and appropriate management can reduce morbidity and mortality. In this issue of Pediatric Emergency Medicine Practice, the epidemiology, pathophysiology, diagnosis, and management of pneumothorax as relevant to practice in the emergency department (ED) are reviewed.
A review of the relevant literature was performed using PubMed, Google Scholar, MEDLINE®, and the Cochrane Database of Systematic Reviews, with search terms including: pneumothorax, pneumothoraces, pediatric pneumothorax, thoracic trauma, tube thoracostomy, pigtail catheter, simple aspiration, lung ultrasound, focused assessment with sonography in trauma (FAST), and pre-hospital care. A total of 163 articles published over the past 3 decades were reviewed. A search of the Cochrane Database of Systematic Reviews for the terms pediatric pneumothorax and pneumothoraces in children did not produce any results. Guidelines from the American College of Chest Physicians (ACCP) from 20012, British Thoracic Society (BTS) from 20033, and Belgian Society of Pneumology (BSP) from 20054 presented excellent, evidence-based approaches to pneumothorax in adults, but offered no specific guidance to management in the pediatric population. With these limitations in mind, relevant management recommendations from the adult literature can still be extrapolated to the pediatric population.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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Matthew Harris, MD; Joshua Rocker, MD
March 2, 2017
April 1, 2020
Physician CME Information
Date of Original Release: March 1, 2017. Date of most recent review: February 15, 2017. Termination date: March 1, 2020.
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