Radiologic Evaluation of Alternative Sites for Needle Decompression of Tension Pneumothorax

Abstract

To compare the distance to be traversed during needle thoracostomy decompression performed at the second intercostal space (ICS) in the midclavicular line (MCL) with the fifth ICS in the anterior axillary line (AAL). Design: Patients were separated into body mass index (BMI) quartiles, with BMI calculated as weight in kilograms divided by height in meters squared. From each BMI quartile, 30 patients were randomly chosen for inclusion in the study on the basis of a priori power analysis (n=120). Chest wall thickness on computed tomography at the second ICS in the MCL was compared with the fifth ICS in the AAL on both the right and left sides through all BMI quartiles. Setting: Level I trauma center. Patients: Injured patients aged 16 years or older evaluated from January 1, 2009, to January 1, 2010, undergoing computed tomography of the chest. Results: A total of 680 patients met the study inclusion criteria (81.5% were male and mean age was 41 years [range, 16-97 years]). Of the injuries sustained, 13.2% were penetrating, mean (SD) Injury Severity Score was 15.5(10.3), and mean BMI was 27.9 (5.9) (range, 15.4-60.7). The mean difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL was 12.9 mm (95% CI, 11.0-14.8; PϽ.001) on the right and 13.4 mm (95% CI, 11.4-15.3; P Ͻ.001) on the left. There was a stepwise increase in chest wall thickness across all BMI quartiles at each location of measurement. There was a significant difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL in all quartiles on both the right and the left. The percentage of patients with chest wall thickness greater than the standard 5-cm decompression needle was 42.5% at the second ICS in the MCL and only 16.7% at the fifth ICS in the AAL. Conclusions: In this computed tomography-based analysis of chest wall thickness, needle thoracostomy decompression would be expected to fail in 42.5% of cases at the second ICS in the MCL compared with 16.7% at the fifth ICS in the AAL. The chest wall thickness at the fifth ICS AAL was 1.3 cm thinner on average and may be a preferred location for needle thoracostomy decompression.

Traumatic cardiac arrest

“…However, depending on the needle or cannula used, this is often ineffective at relieving the tension, as the needle may not be long enough to reach the pleural space, and it may dislodge or kink, rendering it useless, potentially allowing the tension pneumothorax to recur. 16,17 Thoracostomy is therefore recommended over needle decompression. [18][19][20] Thoracostomy is achieved by making a skin incision followed by blunt dissection with forceps or finger through the intercostal muscles and pleura in the same location that an intercostal drain is usually placed (fourth or fifth intercostal space, in the mid-axillary line).…”

Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience

“…This clinical success rate seems exceptionally high considering evidence suggesting that NT may fail to decompress TPTX in up to 50% of patients. [9][10][11][12]27 Furthermore, because a similar rate of clinical improvement was reported in patients surviving their injuries as in patients who did not survive, it seems that these high success rates are the result of inaccurate subjective assessment. In the present study, 32% of patients undergoing NT eventually had a CD installed in the prehospital setting, implying a true failure rate more consistent with that reported in the available literature.…”

“…[10][11][12] In other reports, techniques such as cadaver dissection 13,14 and ultrasonography 15,16 were used to detect the penetration of catheters. On the basis of these findings, a recommendation for change was issued, and many prehospital organizations have adopted the use of longer catheters.…”

“…12,14 Others raised concerns regarding the function of the NT inserted in this site, and both insertion site options are currently considered valid. 4 Despite these and other concerns, the current recommended needle used for decompression is a 14-gauge angiocatheter.…”

Penetrating Injuries to the Lung and Heart: Resuscitation, Diagnosis, and Operative Indications

“…Cadaver [47], animal [48][49][50], and clinical [51][52][53][54] studies have suggested that use of a small (3.2 cm) needle in the standard site (second intercostal space, midclavicular line) is not reliable, likely due to the thickness of the chest wall at this site and the small size of the needle or catheter. Even when proper placement is confirmed laparoscopically in animal models, Martin and colleagues showed that a 14-gauge angiocatheter fails to relieve tension physiology 64 % of the time [48].…”