ECMO-/ECLS

years of age may be difficult. If access is not obtained in 2 attempts or 90
seconds, intraosseous access should be obtained without delay. During
resuscitation the mechanism of injury and external signs of thoracic injury
should be assessed to determine the etiology of cardiovascular collapse. Life-
threatening conditions associated with thoracic injuries include tension
pneumothorax, massive hemothorax, cardiac tamponade, and cardiac arrest.
A patient that has suffered blunt or penetrating chest injury to the chest
presenting with hypotension and unilateral diminished breath sounds should be
quickly assessed for tension pneumothorax. The trachea is evaluated for
midline position and the internal jugular veins are examined for distention.
Tension pneumothorax is a clinical diagnosis and treatment should not be
delayed for radiographic imaging. If the constellation of signs and symptoms
are present and clinical suspicion is high, needle thoracostomy should be
performed immediately. Introduction of a large bore angiocatheter in the 2nd
intercostal space, mid-clavicular line to the affected side will evacuate the
pleural space of air and alleviate tension physiology. Chest tube thoracostomy
is subsequently performed to definitively address the pneumothorax.
If the patient is hemodynamically unstable with unilateral diminished
breath sounds and does not clinically appear to be demonstrating tension
physiology, hemorrhage into the chest may potentially be the cause of shock. If
the patient responds to fluid resuscitation, a prompt chest x-ray should be
performed to evaluate for a large hemopneumothorax. A FAST exam could
also be performed to rule out intra-abdominal free fluid and pericardial effusion.