8. As our population becomes more obese, the distance the needle must traverse becomes longer and the concern that the pleural space is not reached is heightened. Britten S, Palmer SH. A 2003 case series presented three patients with pneumothoraces who were needle-decompressed in the 2ICS-MCL and eventually developed life-threatening intrathoracic hemorrhages.13 The author’s concern was that this location was in close proximity to the subclavian vessels and internal mammary artery and its medial branches.13 A separate 2003 case report actually described cardiac tamponade from laceration of the pulmonary artery.3. Prehosp Emerg Care, 2009 Jan-Mar; 13(1): 14–7. 2011 Nov;71(5):1099-103; discussion 1103. doi: 10.1097/TA.0b013e31822d9618. If the patient has either a closed or open tension pneumothorax, then the need for a needle decompression is required to save the patient. Insert the 14 or 16 gauge angiocatheter with needle placed just above the rib, perpendicular to the skin. BMJ, 1993; 307: 114–16. Furthermore, the lateral approach on the left significantly increased the risk of damaging vital structures, mainly the left ventricle, when using an 8-cm needle.5. They visually observed bending/kinking of the catheters at the midaxillary line, especially when straps were placed to secure the arms in the adducted position. Prehosp Emerg Care, 2008 Apr–Jun; 12(2): 162–8. This involves using a needle catheter to release the trapped air in the pleural space. Needle decompression can be considered as a temporising measure while preparing to place a chest tube for a patient with tension pneumothorax. Results showed that the standard 4.6-cm catheter would reach the pleural space in 52.7% of the population, the 5.1-cm catheter would reach it in 64.8%, and the 6.4-cm catheter would reach it in 79%.4 Similarly, a 2009 study looked at chest wall thickness at the 2ICS-MCL in trauma patients. In general pleura lies two intercostal spaces below the lung (6, 8 & 10th IC space) in midclavicular line (8th), midaxillary line (10th), and paravertebral line (12th). Due to the high failure rates studies have been done and found out that the chest wall was smallest at the 4th and 5th intercostal space anterior axillary line, thicker at 4th and 5th intercostal space mid axillary line and thickest at 2nd intercostal space mid clavicular line. Bethesda, MD 20894, Copyright Careers. 1. 2010 Jun;62(3 Suppl 1):165-7. Here is the needle.” As you’re about to decompress the patient with a 14-gauge angiocatheter, you wonder if there is a better place to do it. Conclusions: Chest wall thickness may limit adequate drainage of tension pneumothorax by needle thoracocentesis. performed a retrospective review of 100 CT scans from trauma patients comparing CWT and radiographic decompression success rates using 5-cm versus 8-cm angiocatheters. Acad Emerg Med, 2011 Oct; 18(10): 1,022–6. © 2021 HMP. The next logical step was to assess the differences in radiographic decompression using a longer needle. J Am Coll Surg. Chang SJ, et al. There is evidence from computed-tomography and cadaveric studies that the chest wall thickness at these sites may be comparable to the site of anterior approach. 11. Unsurprisingly, the longer the catheter length, the higher the predicted success rate. Needle decompression: 2nd Intercostal Space at the Midclavicular Line (Front) 5th Intercostal Space at the Anterior Axillary line; We can also apply almost any internal or external injury to baby, child or adult SIMBODIES Manikins or actors. As such, it is difficult to make a new Grade A recommendation to transition to the fourth/fifth intercostal space at the anterior axillary line as the primary site for needle decompression. 10. 4. One weakness in these studies is that when patients are needle-decompressed, they are lying supine with their arms at their sides and breast tissue falling to dependent positions, usually laterally. The angiocatheter was then transduced using standard arterial line manometry, and the opening pressures required to initiate flow through the catheters were measured. Lastly it is important to point out that although a healthcare practitioner may know the proper site, that does not mean they can find it. Daniel Charles Kolinsky, MD, is a second-year emergency medicine resident physician at Washington University in St. Louis, and a graduate of Louisiana State University Health Sciences Center. The study concludes that although their evidence suggests a lateral approach, trials with living humans are necessary before a change in practice should be advocated.9, It is often overlooked that the instruments used to decompress a patient with a tension pneumothorax are not primarily designed for this purpose. This underscores the importance of using animal models or cadaver trials. * The needle… Beckett A, et al. J Trauma, 2011; 71: S408–12. 6. Wax DB, et al. When the truck screeches to a stop, you hear the front doors open and people screaming outside. They conducted a retrospective review that compared CWT using CT imaging at the 2ICS-MCL to the fifth intercostal space-anterior axillary line (5ICS-AAL). Needle Decompression for Tension Pneumothorax in Tactical Combat Casualty Care: Do Catheters Placed in the Midaxillary Line Kink More Often Than Those in the Midclavicular Line? Cancer Patients Visited by Pink Fire Truck, Conn. EMS, Hospitals Coordinate Patient Transport with New Technology, Off-Duty Ohio EMT Delivers Baby in Parking Lot, National Organizations Publish Position Paper on Spinal Motion Restriction, EMS Around the World: The Hungarian National Ambulance Service. EMS World is a trademark of HMP. Optimal Positioning for Emergent Needle Thoracostomy: A Cadaver-Based Study. 2018 Summer;18(2):19-35. In the series of studies focusing on ND, a trend of increasing needle length has been seen. Inaba K, et al. ... in favor of the left 4th or 5th intercostal space in the mid-axillary line. Emergency department doctors were below the 5th intercostal space in 64% of cases. Methods: J Accid Emerg Med, 1996 Nov; 13(6): 426–7. Mil Med Res. Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. However, in the CT scanner, the arms are positioned above the head, which stretches and thins the muscles of the chest wall and redistributes breast tissue across the chest. Those authors strapped porcine chest walls to the chest wall of a volunteer soldier and performed ND, then prepped the patient on a military stretcher with arms adducted for a simulated two-minute transport. - Other alternative sites for needle decompression include placement at the fourth or fifth intercostal space in the anterior axillary line or at the midaxillary line. Cadaver studies have shown improved success in reaching the thoracic cavity when the fourth or fifth intercostal space mid-axillary line is used instead of the second intercostal space mid-clavicular line in adult patients. Suggested size for adults is 10 gauge x 3.25 inch However, within the last 15–20 years, this has come into question on multiple fronts. (U.S. Space Force photo by Senior Airman Danielle D. McBride) 2. Tension Pneumothorax (TP) is one of the commonest complication of chest trauma. Please enable it to take advantage of the complete set of features! ATLS now recommends this location for needle decompression … J Trauma. Increasingly, interest has focused on the lateral approach for needle decompression, either at the mid-axillary line or at the anterior axillary line, in the fifth intercostal space. West J Emerg Med, 2013; 14(6): 650–2. This may contribute to the reaccumulation of tension pneumothoraces and ultimate patient deterioration in military transport. It is widely accepted that chest drains for definitive management are placed in the 5th ICS mid axillary line so why not opt for this site for emergency decompression? 6 However, there may be a higher complication rate with this site as pleural adhesions are … Based on the patterns seen in these studies, one can conclude that the 8-cm needles will maximize success rates independent of approach. You start your ATLS exam. 5. The heart is present on the left side. J Trauma Acute Care Surg, 2014 Apr; 76(4): 1,029–34. Advanced Trauma Life Support (ATLS) Tips to Be Kept In Mind. With the increase in needle length, success of radiographic decompression increased. ... with needle decompression, a … To perform needle decompression, the needle should be inserted in the second intercostal space at the midclavicular line. Needle decompression (ND) is a critical TCCC intervention, because previous data suggest that up to 33% of all preventable deaths on the battlefield result from tension pneumothoraces. Prep the area. His professional interests include medical education, patient-physician dynamics, and EMS critical care. Breathing is clear on the left, decreased breath sounds on the right. Chest Tube placement is only after the Needle Decompression of Thorax has been completed; Indications for operative management in Traumatic hemothorax. Privacy, Help • Locate the second (2nd) intercostal space mid- clavicular line, or the fifth (5th) intercostals space mid-axillary line • Prepare the site with aseptic technique using betadine solution (swab) • Insert the needle at the second intercostal space at the mid-clavicular line, directing the needle just over the top of the third rib to avoid the intercostal vessels and nerves. The reason makes sense. Based on the current evidence, advocating for a change in primary site selection is premature. J Spec Oper Med. However, note that with such long needles, the lateral approach may increase risk of injury to proximal vital structures. A needle decompression involves inserting a large-bore needle into the second or fifth intercostal space to release the trapped air compressing the lung. 4th or 5th intercostal space in the anterior axillary line This was better quantified by indirectly measuring the threshold pressures to initiate flow through the catheter. The data are unclear whether chest wall thickness is greater at the 2ICS-MCL or the 4/5ICS-MCL. When making the incision, make it one rib below the intercostal space you want to insert the tube into. This unfortunate fact was confirmed in a 2005 study that included 25 emergency medicine physicians, 21 of whom were ATLS-certified.8 Twenty-two (88%) of the physicians named a correct location, but only 15 (60%) were able to identify it on a human volunteer. 2008 Aug;207(2):174-8. doi: 10.1016/j.jamcollsurg.2008.01.065. Stevens RL, et al. With the growth of size in our population worldwide, there has been increasing evidence about two things: 15. A needle decompression involves inserting a large bore needle in the second intercostal space… Carter TE, et al. He completed his emergency medicine residency at Barnes Jewish Hospital/Washington University in Saint Louis and his EMS fellowship at the University of North Carolina in Chapel Hill. The new spot is the typical location for placement of the inevitable chest tube that has to be inserted after needle decompression. These studies present weak if not conflicting data. A tube thoracostomy was performed as a rescue intervention and restored perfusion in eight of the nine NT failures.11. Minerva Pediatr. A novel optical technology based on 690 nm and 850 nm wavelengths to assist needle thoracostomy. There has recently been increased interest in performing ND at the fifth intercostal space in the midaxillary line to prevent complications associated with landmarking second intercostal space in the midclavicular line site. J Trauma Acute Care Surg, 2012 Dec; 73(6): 1,412–7. Warner KJ, Copass MK, Bulger EM. This study suggests that the 14-gauge, 1.5-inch angiocatheter used for ND in the midaxillary line may partially and temporarily occlude in patients who will be transported on military stretchers. 2. ATLS: Advanced Trauma Life Support—Student Course Manual, 9th ed. Needle Decompression is not the only way to relieve a tension pneumothorax, remember that simply lifting the seal and "burping" the wound may relieve the trapped air. The opening pressures were then converted to mm Hg. This issue was examined by a series of retrospective studies that utilized CT imaging to document chest wall thickness (CWT) and radiographic decompression based on catheter length. Inaba K, et al. If the anterior (MCL) site is used, do not insert the needle medial to the nipple line. Hawnwan Philip Moy, MD, is an assistant medical director of the Saint Louis City Fire Department, and emergency medicine clinical instructor and core faculty of the EMS Section of the Division of Emergency Medicine at Washington University in Saint Louis, MO. We developed a model to assess whether catheters placed in the midaxillary line for decompressing tension pneumothoraces are more prone to kinking than those placed in the midclavicular line because of adducted arms during military transport. All Rights Reserved. The TruMan Trauma X pneumothorax manikin also comes supplied with torso inserts for practicing needle decompression in the 5th intercostal space. A 2011 cadaver study showed that the success rate for … In the second arm, there were 14 tension pneumothoraces with PEA events treated initially with ND. The anatomical location to insert the needle was 2nd intercostal space mid clavicular line. There have been reports where decompression through 2ICS MCL has failed to release a tension pneumothorax, possibly because of insufficient cannula length, 6– 9 and it has been postulated that the fifth intercostal space, anterior axillary line may be preferable as it avoids the bulky anterior chest wall muscles. Committee on Trauma, American College of Surgeons. Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. You palpate weak pulses in the bilateral radial wrists. To simulate ND, we secured segments of porcine chest walls over volunteer soldiers' chests and placed 14-gauge, 1.5-inch angiocatheters through the porcine wall segments which were affixed to either the midaxillary or midclavicular location on the volunteers. J Trauma, 2011; 71: 1,099–103. You’re a young resident physician on the first ridealong of your EMS rotation. Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. J Trauma Acute Care Surg. Emerg Med J, 2003 Jul; 20(4): 383–4. An alternative site may be needed. However, there are some valuable conclusions that can be drawn from this pool of data. Accessibility This was one of the many techniques used by medics during the TCCC exercise and on the battlefield. Butler KL, et al. Paramedic use of needle thoracostomy in the prehospital environment. This is especially true with larger holes that were actively sucking air in prior to chest seal placement. The horizontal fissure (only on the right) starts at the 4th rib at the sternum and then meets the oblique fissure at the 5th rib in the midaxillary line. 4. Her airway is midline and patent. Using a 5-cm needle, 42.7% of needle decompressions would be expected to fail at the 2ICS-MCL, compared to 16.7% at the 5ICS-AAL.10 These results were contradicted by a review done by Leon Sanchez, MD, et al. The needles were secured and thoracotomy was then performed to … * Either the 5th intercostal space (ICS) in the anterior axillary line (AAL) or the 2nd ICS in the mid-clavicular line (MCL) may be used for needle decompression (NDC.) NDs were performed on both the right and left sides using a 5-cm catheter. Of the 14 that remained patent at five minutes, six failed to relieve tension physiology, for an overall failure rate of 58%. 2016 Feb;80(2):272-7. doi: 10.1097/TA.0000000000000889. Epub 2008 May 12. J Trauma, 2003; 54: 610–11. Background: Currently the Advanced Trauma Life Support (ATLS) guidelines recommend initial treatment of decompression of a tension pneumothorax, as needle thoracostomy (NT) using a 5cm angiocatheter at the 2 nd intercostal space (ICS2) in the mid clavicular line (MCL). Arch Surg, 2012 Sep; 147(9): 813–8. Using a 5-cm needle, radiographic decompression was achieved 66%–76% of the time at the 2ICS-MCL and 75%–81% of the time at the 4ICS-AAL. The majority of the aforementioned studies comparing chest wall thickness were based on radiographic measurements alone. Defense Health Board. Furthermore, the NT was successful 100% of the time in the 5ICS-MAL bilaterally versus 60% on the right and 55% on the left in the 2ICS-MCL, both of which were statistically significant. Furthermore, the CWT was statistically greater at the 2ICS-MCL compared to the 5ICS-AAL. Location for needle decompression 2nd intercostal space at mid-clavicular line or 5th intercostal space at mid-axillary line; Cleanse the area with an alcohol or betadine preparation; For adult, use largest, longest available angiocath. Check the patient for signs and symptoms of relief. 16. Sci Rep. 2021 Feb 16;11(1):3874. doi: 10.1038/s41598-021-81225-4. Lee CC, Chuang CC, Lu CL, Lai BC, So EC, Lin BS. For children, a shorter angiocath is appropriate. Prevention and treatment information (HHS). Awareness of site for needle thoracocentesis. 2018 Mar 9;18(1):15-19. doi: 10.1016/j.tjem.2018.01.006. A 14-gauge or 16-gauge catheter is inserted into the affected pleural space at the second intercostal space in the midclavicular line. This has come about because shorter needles may not reach the pleural space when inserted under the clavicle in larger patients. We observed that there was a significant pressure difference required to achieve free flow through the in situ angiocatheter between the fifth intercostal space midaxillary line versus the second intercostal space midclavicular line site (13.1 ± 3.6 mm Hg vs. 7.9 ± 1.8 mm Hg). Once she’s loaded the EMT calls out vitals: heart rate, 60; blood pressure, 70/40; respiratory rate, 22; oxygen saturation, 99%. We then assessed for occlusion and kinking by flow of normal saline (NS) through the angiocatheter in situ. Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02. Providers should only advance the needle far enough to enter the thoracic cavity, and then thread the catheter into this space (similar technique to placing an IV). From the limited number of studies that have looked at differences in site safety, it appears the anterior approach is farther from vital structures and has less of a chance of injury with incorrect needle insertion.5 However, when needle angle is corrected to perpendicular, the risk of injury becomes almost equivalent.5. If this does not relieve the trapped air, the next step is a thoracic decompression, often called needle thoracostomy or needle decompression. So, thoracocentasis can be done at costodiaphragmatic recess through the eighth or ninth intercostal space at the midaxillary line. Needle Decompression in Appalachia Do Obese Patients Need Longer Needles? Unable to load your collection due to an error, Unable to load your delegates due to an error. Pulmonary Artery Injury and Cardiac Tamponade after Needle Decompression of a Suspected Tension Pneumothorax. Tactical Combat Casualty Care (TCCC) is a system of prehospital trauma care designed for the combat environment. Needle decompression (ND) is a critical TCCC intervention, because previous data suggest that up to 33% of all preventable deaths on the battlefield result from tension pneumothoraces. Thus it was concluded that the lateral approach did not work as well as the anterior approach because the catheters were more likely to be kinked and occlude.1, A 2011 study led by Inaba used 20 randomly selected human cadavers to assess differences in CWT (distance) and ND success (entry intro pleural space) between the 2ICS-MCL and the 5ICS-MAL. National Library of Medicine Optimal positioning for emergent needle thoracostomy: a cadaver-based study. in 2011.14 Scans from 159 patients yielded a statistically greater CWT at the fourth ICS and 5ICS-AAL compared to 2ICS-MCL. One study conducted in a U.S. region with a patient population known to have higher obesity rates compared CT radiographic needle compression success based on catheter length. They did not consider variables for which a static image cannot account, such as chest wall compliance and recoil, changes in body positioning and other complications (kinking, occlusion, etc.). Consequently the catheters have an unacceptable and variable rate of failure despite being in the pleural space. As a result, current practice is based on the various smaller retrospective studies. An evaluation of tactical combat casualty care interventions in a combat environment. 2018 Oct 4;5(1):34. doi: 10.1186/s40779-018-0181-6. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. Thirty randomly selected patients from four predefined BMI quartiles were included for a total of 120 patients. This site needs JavaScript to work properly. Economy torso inserts have a single solid layer and are a lower-cost alternative. Use of the iTClamp versus standard suturing techniques for securing chest tubes: A randomized controlled cadaver study. Additionally, the failure rate based on a 5-cm needle at the 2ICS-MCL was lower (33.6%) compared to the 4ICS-MAL (73.6%) and 5ICS-MAL (55.3%), all statistically significant differences.14. Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax. Butler FK Jr, Holcomb JB, Shackelford S, Montgomery HR, Anderson S, Cain JS, Champion HR, Cunningham CW, Dorlac WC, Drew B, Edwards K, Gandy JV, Glassberg E, Gurney J, Harcke T, Jenkins DA, Johannigman J, Kheirabadi BS, Kotwal RS, Littlejohn LF, Martin M, Mazuchowski EL, Otten EJ, Polk T, Rhee P, Seery JM, Stockinger Z, Torrisi J, Yitzak A, Zafren K, Zietlow SP. As patients become larger and the standard catheter length remains unchanged, entering the pleural space becomes more difficult, which may lead to failed decompressions and worse outcomes. The ND failed to restore perfusion in nine events (64%). They make needle decompression kits which typically have the 5 cm angiocath you are looking for. Treatment: Needle decompression. Overall, the 5 th ICS AAL was a superior site for needle decompression based on chest wall measurement; Chest wall thickness was thicker at the 2 nd ICS MCL compared to the 5 th ICS AAL (by 0.5cm) As only 16% of patients had chest walls thicker than the standard 5cm needle commonly used. That location is the 5th intercostal space around the mid-axillary line. As you traverse the pleura, you may hear the distinctive rush of air from the decompressed tension pneumothorax. Aho JM, Thiels CA, El Khatib MM, Ubl DS, Laan DV, Berns KS, Habermann EB, Zietlow SP, Zielinski MD. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. At this time there have been no large-scale prospective randomized controlled trials or meta-analyses that have led to a consensus statement. Premium torso inserts have three layers for skin, fat and muscle tissue for realistic feel and resistance. Ferrie EP, Collum N, McGovern S. The right place in the right space? Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. 2nd intercostal space in the midclavicular line; Difficulty finding the correct anatomical site, often times going too medially 14g angiocath (with 5cm length) will fail to reach the chest cavity in more than 50% of cases; Modern Approach. However, within the last 15–20 years, this has come into question on multiple fronts. Using CT scans of 110 patients, it noted that using a standard-size angiocatheter (4.4 cm), needle decompression would be unsuccessful in 50% of trauma patients based on its patient population.15, Kenji Inaba, MD, and colleagues took this idea one step further. 9. 2008 Jan;64(1):111-4. doi: 10.1097/01.ta.0000239241.59283.03. Colo. Medics Credit Woman For Saving Husband's Life with CPR, EM Innovations Introduces New Handheld Suction Device, Child’s Play: Scoop-and-Run May Not Be Best for Kids in Cardiac Arrest, Your Captain Speaking: Medication Compliance, Ind. The fourth/fifth intercostal space at the anterior axillary line should be considered in trauma protocols as an alternative site. Samuel Chang, MD, et al. Rawlins R, et al. 8600 Rockville Pike Below the 7th intercostal space 21% of cases (below the 8th in 9% of cases) 3. Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement.
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