Thoracostomy and Thoracotomy for Emergency Management of Pediatric Pleural Space Pathologies (Trauma CME)

Table of Contents

 

About This Issue

There are many pleural space diseases in pediatric patients that can present to the emergency department (ED). The ability to perform urgent interventions for life-threatening pleural space pathologies is essential for emergency clinicians. This issue reviews the clinical indications for thoracostomy and thoracotomy in pediatric patients, outlines procedural considerations, and discusses potential complications in the ED. In this issue, you will learn:

Guidance for prehospital care of patients with a suspected pleural space pathology, including indications for immediate needle thoracostomy, recommendations for pain management, and general considerations for transport

Possible physical examination findings for patients with pleural space pathologies

Which imaging study is the first-line modality for evaluating for pleural space pathology, and when computed tomography is indicated

Recommendations for management of pleural space pathologies in pediatric patients, including preprocedural preparation, pain management, and supportive care

Guidance for performing needle thoracostomy, chest tube thoracostomy, and pigtail catheter thoracostomy

Situations in which emergency resuscitative thoracotomy should be performed in the ED and recommendations for performing the procedure

Advancements in the field that reduce procedural delays and improve patient outcomes

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Pneumothorax
   2. Pleural Effusions
   3. Effects of Impaired Gas Exchange
7. Differential Diagnosis
   1. Pneumothorax
   2. Pleural Effusions
8. Prehospital Care
   1. Decompression
   2. Pain Management
   3. Transport Considerations
9. Emergency Department Evaluation
10. Diagnostic Studies
    1. Chest X-Ray
    2. Ultrasound
    3. Computed Tomography
11. Treatment
    1. Preprocedural Preparation
    2. Pain Management
    3. Supportive Care
    4. Thoracostomy
       1. Needle Thoracostomy
       2. Chest Tube Thoracostomy
       3. Pigtail Catheter Thoracostomy
    5. Thoracotomy
       1. Adult Studies
       2. Pediatric and Adolescent-Specific Studies
12. Special Populations
    1. Obese Patients
    2. Patients With Secondary Pneumothorax
13. Controversies and Cutting Edge
    1. Ultrasound for Pathology Diagnosis and Procedural Guidance
    2. Needle Placement During Decompression
    3. Needle Decompression and Chest Tube Placement Innovations
14. Disposition
15.  Summary
16. Risk Management Pitfalls in the Emergency Department Management of Pediatric Patients With Pleural Space Pathologies
17. 5 Things That Will Change Your Practice
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathway for Emergency Department Thoracotomy in Pediatric Patients With a Traumatic Plural Space Pathology
21. Tables and Figures
22. References

Abstract

While indications and techniques for thoracostomy are well-studied in adults, pediatric-specific evidence remains limited for emergency department-based thoracostomy and especially thoracotomy. The ability to perform urgent interventions for life-threatening pleural space pathologies is essential for all emergency clinicians. This issue reviews the clinical indications for thoracostomy and thoracotomy in pediatric patients, outlines procedural considerations for these techniques, and discusses potential complications in the emergency department. Advancements in the field are also highlighted, including emerging approaches to reduce procedural delays and improve patient outcomes.

Case Presentations

A 16-year-old boy is brought in via EMS after an all-terrain vehicle accident…

• The boy was riding without a helmet when he lost control of his vehicle and hit a tree. He did not lose consciousness, but his chest hit the steering wheel. He has right-sided rib pain and shortness of breath.
• On examination, he has right upper quadrant abdominal tenderness, diaphoresis, tachycardia, and tachypnea, with an oxygen saturation of 93% on room air.
• You order a chest x-ray and begin to think about what interventions are needed…

A 16-year-old boy with increased work of breathing arrives via transfer from a different hospital…

• The boy says he does not have an underlying cardiac or pulmonary history, and he has not been ill or had a fever recently.
• His vital signs are stable. A chest x-ray from the referring hospital shows a moderately sized pneumothorax.
• The pediatric surgical team is unable to come to the ED because they are scrubbed in on a surgical case. They ask if you could place a pigtail catheter if a repeat chest x-ray shows a pneumothorax of equal or larger size.
• You try to remember the best location for insertion of a pigtail in this age group…

A 4-year-old girl who was involved in a shooting arrives to your community hospital…

• The girl has a gunshot wound to her right torso. She is hemodynamically unstable, with respiratory distress and a respiratory rate in the 50s.
• You activate the massive transfusion protocol and call the blood bank to have packed red blood cells on standby.
• Your community hospital lacks the resources to definitively manage this patient, so you consider what stabilization is required prior to transfer…

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Clinical Pathway for Emergency Department Thoracotomy in Pediatric Patients With a Traumatic Plural Space Pathology

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Feller-Kopman D, Light R. Pleural disease. N Engl J Med. 2018;378(18):1754. (Review) DOI: 10.1056/NEJMc1803858

4. * American College of Surgeons. Committee on Trauma. ATLS^® : Advanced Trauma Life Support Student Course Manual. 11th ed. American College of Surgeons; 2025. (Book) ISBN: 9781880696521

55. * Selesner L, Yorkgitis B, Martin M, et al. Emergency department thoracotomy in children: a Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma systematic review and practice management guideline. J Trauma Acute Care Surg. 2023;95(3):432-441. (Systematic review; 319 patients) DOI: 10.1097/TA.0000000000003879

61. * Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79(1):159-173. (Review) DOI: 10.1097/TA.0000000000000648

63. * Moore HB, Moore EE, Bensard DD. Pediatric emergency department thoracotomy: a 40-year review. J Pediatr Surg. 2016;51(2):315-318. (Prospective cohort study; 179 patients) DOI: 10.1016/j.jpedsurg.2015.10.040

76. * Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119(2):590-602. (Review) DOI: 10.1378/chest.119.2.590

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Keywords: thoracostomy, thoracotomy, pleural space pathology, pleural space pathologies, pneumothorax, spontaneous pneumothorax, primary pneumothorax, secondary pneumothorax, pleural effusion, empyema, hemothorax, chest x-ray, deep sulcus sign, ultrasound, barcode sign, atmosphere sign, lung point, computed tomography, needle decompression, needle thoracostomy, pigtail catheter, chest tube, transport considerations