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HWN Suggests

Needle Thoracostomy: Can we all agree to stop sticking needles in the 2nd Intercostal space?

Representative case series of hundreds of patients support the ideal NT site for all-comer adult (and less so pediatric) trauma patients with suspected tension pneumothorax as a 14 gauge or greater angiocath that is >4.5 cm or longer for larger body habitus patients. NT should be performed at the 4th or 5th ICS in the MAL or AAL, with the best location likely the 5th ICS at the AAL due to CWT and better margin of error in nearby structures.

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  Needle vs. Knife II: Needle Thoracostomy (Decompression)?

In this podcast, I explain why I don't think needle compression is such a clever idea. Main points are: most people can't find anterior target, most angiocaths won't reach, and if used diagnostically you may not be in the pleura leading to an unidentified pneumo or hemothorax. Also, when used diagnostically, if the chest was negative you just caused a pneumothorax.

 Podcast 541: Needle Thoracostomy

Traditional technique of needle thoracostomy for tension penumothorax is along the 2nd intercostal space at the midclavicular line Inserting a large angiocatheter along the 4th or 5th intercostal space at the mid-axillary line may provide a thinner area that is more easily identified, overcoming many of the obstacles of the traditional approach The 10th Edition of ATLS now recommends this location as well

 What is the Best Anatomic Location for Needle Thoracostomy?

Best evidence suggests that the 4th/5th ICS-AAL has the lowest predicted failure rate of needle decompression with a 5cm angiocatheter Given the increasing BMI of the population, a 5cm angiocatheter may not be long enough to reach the pleural space, but must be balanced with a risk of causing injury to vital structures with longer needles.

Articles of Interest

Association of Prehospital Needle Decompression With Mortality Among Injured Patients Requiring Emergency Chest Decompression

Prehospital needle decompression (PHND) is a rare but potentially life-saving procedure. Prior studies on chest decompression in trauma patients have been small, limited to single institutions or emergency medical services (EMS) agencies, and lacked appropriate comparator groups, making the effectiveness of this intervention uncertain.

Emergent needle thoracostomy in prehospital trauma patients: a review of procedural execution through computed tomography scans

Improperly placed NT insertion into the pleural cavity may fail to treat a life-threatening TPT. Prior studies suggested that ineffective treatment of an existing TPT may be caused by insufficient angiocatheter length, inaccurate angiocatheter placement, or a blockage of the angiocatheter such as from blood clots or kinks.

Evidence-Based EMS: Needle Decompression

A retrospective review of patients undergoing needle decompression by prehospital providers concluded the procedure is safe to perform and, when done in the decompensating trauma patient, can have beneficial outcomes.

Finger/Needle Thoracostomy

Needle thoracostomy has been traditionally recommended over finger thoracostomy, although care must be taken to ensure adequate needle length and proper technique to avoid failure.

More on needle thoracostomy for tension pneumothorax

The take home message for us must therefore remain that needle thoracostomy for tension pneumothorax might not be successful with a standard iv catheter, regardless of which approach is used. If tension pneumothorax is a possibility in the deteriorating patient and needle decompression has been unsuccessful, an alternative means of decompression (or ruling out pneumothorax) must be employed.

Needle thoracostomy for tension pneumothorax

This is how we perform needle thoracostomy for tension pneumothorax in Trauma. This video was created by Drs. Jean Chen and Stella Yiu.

Optimal Needle Position for Decompression of Tension Pneumothorax

In this heterogenous patient population, ICS2-MCL seems to be the preferred anatomical location for tension pneumothorax decompression for overweight- and obese subjects compared to the ICS4/5-AAL using standard large bore catheters (45 mm and 50 mm).

Optimal Positioning of Emergent Needle Thoracostomy: A Cadaver-Based Study

This cadaver study reinforces prior computed tomography studies, which have found that chest wall thickness in up to half of the population is greater than the standard catheter length recommended for NT. Thus, the thinner chest wall at the fifth intercostal space likely contributed to greater success rates of NT.

Simple Thoracostomy: Moving Beyond Needle Decompression in Traumatic Cardiac Arrest

Simple thoracostomy is a safer method than needle thoracostomy.

Tension pneumothorax – time to change the old mantra?

In treating a tension pneumothorax, we have traditionally been taught to place a large bore catheter in the second intercostal place (2nd ICS) mid-clavicular line, and this method is still advocated in ATLS guidelines. It is the obvious choice in terms of ease of anatomical location where speed is of the essence with a time-critical injury. However, this approach may not be the most effective position to provide live-saving decompression and there is conflicting, and a lack of quality, evidence to support the 2nd ICS approach.