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or aggressive resuscitation Pneumothorax is more common in premature infants with surfactant deficiency or meconium aspiration If significant respiratory distress is present and a pneumothorax is suspected, rapid decompression may be achieved with a large syringe, 20-gauge needle, or catheter over needle using a three-way stopcock The needle is advanced at the fourth intercostal space in the anterior axillary line or the second interspace in the midclavicular line Subsequently, a chest tube (8F) may be placed using a standard technique (see Chapter 130 Procedures ) Congenital Diaphragmatic Hernia CDH is a true neonatal emergency; the diagnosis is confirmed by a chest radiograph showing bowel gas within the thorax ( Fig 9.19 ) Infants with CDH require emergent ET intubation to avoid excessive amounts of air accumulation in the bowel A nasogastric tube should be rapidly placed to decompress the stomach The infant must be rapidly evaluated by a pediatric surgeon after ventilation is stabilized and venous access is achieved TEAMWORK IN RESUSCITATION FOR ALL PEDIATRIC PATIENTS Existing resuscitation curricula of the AHA incorporate learning modules on leadership, role clarity, and communication Effective leaders and team members must have cognitive (fund of knowledge), technical and procedural, and behavioral skills Postresuscitation team debriefing is increasingly recognized as a critical component in maintaining effective teamwork and communication skills in pediatric resuscitations Recent information reveals lack of effective teamwork skills and its negative impact on outcomes Effective education includes challenging hands-on active exercises, such as role play and high-fidelity simulation A formal process for the review of video recordings of resuscitations provides another avenue for identifying opportunities for improving care processes and for providing constructive feedback on team management skills Maintenance of competency for physicians working in ED settings includes procedural and leadership competencies Developing and maintaining the ability to effectively lead a multidisciplinary team in a high-stakes, high-risk, error-prone environment is necessary and must be thoughtfully considered in this era of decreasing frequency of individual exposure to these patients Finally, parental presence in the resuscitation room is recommended by the AAP and should be routine practice All EDs should have a written policy and a process in place, and all families should be offered this opportunity for family presence (see Chapter A General Approach to the Ill or Injured Child )