dilator, and advance the thoracostomy catheter with a twisting motion over the wire into the pleural space For catheters with a coiled tip, a second person is often needed to uncoil the tip to place it over wire Do not lose hold of the wire during this process Insert the tube to the estimated depth (see section Insertion of a Chest Tube) with all drainage holes within the chest Attach to a pleural drainage unit Suture in place Apply an occlusive dressing Extra tape to the chest wall should be used to avoid accidental dislodgement Obtain an upright or decubitus chest radiograph to document position of the tube ( Fig 130.25 ) PERICARDIOCENTESIS Indications Emergent removal of intrapericardial fluid in the treatment of cardiac tamponade Elective removal of pericardial fluid in the presence of a chronic or recurrent pericardial accumulation leading to an impairment of cardiac output Diagnostic procedure for direct analysis of pericardial fluid Complications Acute Myocardial penetration and aspiration of ventricular blood Cardiac arrhythmias New hemopericardium Pneumothorax Coronary artery or vein laceration Diaphragmatic perforation Puncture of peritoneal cavity Delayed Pericardial leakage and development of a cutaneous fistula Pericardioperitoneal fistula Slowly developing pneumothorax Pneumopericardium Local infection Hemorrhagic pericardial effusion leading to pericardial tamponade Peritonitis from puncture of peritoneal cavity Equipment Povidone-iodine antiseptic solution; sterile drapes, sterile gauze, gloves; 1% lidocaine, 3- to 5-mL syringe; 22-gauge needle; 20-gauge, 2.5- or 3.5-in spinal needle or long (6 in) over-the-needle catheter; three-way stopcock; 20- and 50mL syringes; sterile alligator clip (optional); flexible sterile guide wire (0.018 in); soft infusion catheter (18 or 20 gauge); no 15 scalpel blade and holder Flexible catheter kits are also available, similar to the “pigtail” catheters used for thoracostomy Procedure Position the child supine at a 30- to 45-degree angle to the horizontal plane Sedation usually is required, and may necessitate airway management and assisted ventilation to ensure the safety of the child Attach the limb leads of an electrocardiogram (ECG) monitor Clean and sterilize the precordium with antiseptic solution, and donning sterile gloves, drape the area with sterile towels Infiltrate the area to cm below and to the patient’s left of the xiphoid process with 1% lidocaine; infiltrate the muscle layer to achieve satisfactory local anesthesia Attach the spinal needle to a stopcock and a 20- to 50-mL syringe If available, connect the “V” lead of the ECG to the hub of the needle with a sterile clip (alligator type) after checking that the lead is grounded ( Fig 130.26A ) Turn the ECG recorder on to the “V” lead position Before inserting the needle, make a 2-mm incision to cm below and slightly to the patient’s left of the xiphoid to facilitate penetration of the skin Holding the needle perpendicular to the skin, advance it through this incision Once below the skin, angle the needle at approximately 45 degrees up from the abdominal surface, pointing cephalad and toward the tip of the left scapula Slowly advance, maintaining a slightly negative pressure on the syringe Monitor the ECG during this procedure Close observation for a change in the ECG serves as a guide to the depth of the needle penetration Advance the needle until pericardial fluid is obtained or evidence of myocardial contact is seen on ECG The appearance of a widened and enlarged QRS complex or a “current of injury” pattern (ST segment changes and T-wave inversion) indicates penetration beyond the pericardium and into the myocardium If this occurs as shown in Figure 130.26B , withdraw the needle and observe closely for the return of the baseline pattern of the ECG ( Fig 130.26A ) Alternatively, ultrasound can be used to localize the drainage site Once in the pericardial space, the syringe fills with the pericardial fluid If drainage of a large volume of fluid is anticipated, introduce a flexible wire through the indwelling needle, followed by an end-hole catheter passed over the wire into the pericardial space FIGURE 130.25 Insertion of a thoracostomy catheter using the Seldinger technique An alternative to using a spinal needle and the Seldinger technique for introduction of the catheter is to use a long over-the-needle catheter attached to the syringe and stopcock When the tip of the needle has passed into the pericardial space, the catheter can be advanced and the needle withdrawn, leaving the drainage catheter and stopcock assembly in place for future drainage needs After the procedure is complete, remove the needle (or catheter) and cover the puncture site with a sterile dressing Observe the patient closely with frequent vital sign checks, until stable, in the intensive care unit Obtain an upright chest radiograph to assess for complications or a reaccumulation of pericardial fluid Ultrasound can also be used to monitor the pericardial space NASOGASTRIC TUBE PLACEMENT Indications Decompression of the stomach and proximal bowel for obstruction or trauma Gastric lavage in the child with upper gastrointestinal (GI) bleeding or an ingestion/overdose Administration of medication, rehydration solution, or nutrition Obtaining gastric content samples for laboratory analysis Complications Tracheal intubation Nasal, pharyngeal, or esophageal trauma or laceration Reflux or vomiting leading to aspiration Direct airway instillation of tube contents—medications, tube feeds, etc Note: Nasogastric tube placement may be contraindicated in patients with known or suspected anterior fossa skull fractures or severe maxillofacial injuries Orogastric tube placement may be used in these situations