Needle Thoracostomy in the Treatment of a Tension Pneumothorax in Trauma Patients: What Size Needle?

Department of Traumatology, University Hospital Maastricht, The Netherlands.
The Journal of trauma (Impact Factor: 2.96). 01/2008; 64(1):111-4. DOI: 10.1097/01.ta.0000239241.59283.03
Source: PubMed


A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5-cm (2-inch) catheter (5-cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle.
To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces.
Retrospective review of major trauma admissions (Injury Severity Score >12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, <40 years of age and >/=40 years of age was defined a priori. CWT was measured to the nearest 0.01 cm at the second ICS in the MCL.
The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50 cm at the left second ICS MCL and 3.51 cm on the right. The mean CWT was significantly higher for women than men (p < 0.0001). About 9.9% to 19.3% of the men had a CWT >4.5 cm and 24.1% to 35.4% of the women studied.
A catheter length of 4.5 cm may not penetrate the chest wall of a substantial amount (9.9%-35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy.

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Available from: Peter R G Brink, Jan 17, 2014
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    • "Placement of the needle in the abdominal cavity, a solid organ, or the heart, would limit the use of a change of site for this blind technique. Two other studies were published with similar hypotheses and design in Canada and Japan, both of which have a smaller percentage of adult populations suffering from obesity.3,4 All 3 of these studies focused on trauma populations that are predominately young males with primarily penetrating injuries. "
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    ABSTRACT: Needle decompression of a tension pneumothorax can be a lifesaving procedure. It requires an adequate needle length to reach the chest wall to rapidly remove air. With adult obesity exceeding one third of the United States population in 2010, we sought to evaluate the proper catheter length that may result in a successful needle decompression procedure. Advance Trauma Life Support (ATLS) currently recommends a 51 millimeter (mm) needle, while the needles stocked in our emergency department are 46 mm. Given the obesity rates of our patient population, we hypothesize these needles would not have a tolerable success rate of 90%. We retrospectively reviewed 91 patient records that had computed tomography of the chest and measured the chest wall depth at the second intercostal space bilaterally. We found that 46 mm needles would only be successful in 52.7% of our patient population, yet the ATLS recommended length of 51 mm has a success rate of 64.8%. Therefore, using a 64 mm needle would be successful in 79% percent of our patient population. Use of longer length needles for needle thoracostomy is essential given the extent of the nation's adult obesity population.
    The western journal of emergency medicine 11/2013; 14(6):650-2. DOI:10.5811/westjem.2013.7.15844
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    • "Finally, the idea that longer angiocatheters may be indicated for needle thoracostomy ignores the potential for increased numbers of iatrogenic injuries. In the recent article by Zengerink et al [8], they note a 2.4% prevalence at which a 4.5-cm needle could pierce pericardium at the left second IC space, midclavicular line. Butler et al [19] report a case of pulmonary artery injury and cardiac tamponade after left-sided needle decompression at the second left ICS. "
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    ABSTRACT: Computed tomography measurements of chest wall thickness (CWT) suggest that standard-length angiocatheters (4.5 cm) may fail to decompress tension pneumothoraces. We used an alternative modality, ultrasound, to measure CWT. We correlated CWT with body mass index (BMI) and used national data to estimate the percentage of patients with CWT greater than 4.5 cm. This was an observational, cross-sectional study of a convenience sample. We recorded standing height, weight, and sex. We measured CWT with ultrasound at the second intercostal space, midclavicular line and at the fourth intercostal space, midaxillary line on supine subjects. We correlated BMI (weight [in kilograms]/height(2) [in square meters]) with CWT using linear regression. 95% Confidence intervals (CIs) assessed statistical significance. National Health and Nutrition Examination Survey results for 2007-2008 were combined to estimate national BMI adult measurements. Of 51 subjects, 33 (65%) were male and 18 (35%) were female. Mean anterior CWT (male, 2.1 cm; CI, 1.9-2.3; female, 2.3 cm; CI, 1.7-2.7), lateral CWT (male, 2.4 cm; CI, 2.1-2.6; female, 2.5 cm; CI 2.0-2.9), and BMI (male, 27.7; CI, 26.1-29.3; female, 30.0; CI, 25.8-34.2) did not differ by sex. Lateral CWT was greater than anterior CWT (0.2 cm; CI, 0.1-0.4; P < .01). Only one subject with a BMI of 48.2 had a CWT that exceeded 4.5 cm. Using national BMI estimates, less than 1% of the US population would be expected to have CWT greater than 4.5 cm. Ultrasound measurements suggest that most patients will have CWT less than 4.5 cm and that CWT may not be the source of the high failure rate of needle decompression in tension pneumothorax.
    The American journal of emergency medicine 10/2010; 29(9):1173-7. DOI:10.1016/j.ajem.2010.06.030 · 1.27 Impact Factor
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    ABSTRACT: In hospital practice pleural aspiration (thoracocentesis) and chest drain insertion may be required in many different clinical settings for a variety of indications. Doctors in most specialities will be exposed to patients requiring pleural drainage and need to be aware of safe techniques. There have been many reports of the dangers of large bore chest drains and it had been anticipated that with the previous guidelines, better training and the advent of small bore Seldinger technique chest drains, that there would have been an improvement. Unfortunately the descriptions of serious complications continue and in 2008 the NPSA (National Patient Safety Agency) issued a report making recommendations for safer practice 1. These up-dated guidelines take into consideration the recommendations from this report; describe the technique of pleural aspiration and Seldinger chest drain insertion; and ultrasound guidance. Much of this guideline is descriptions of how to do these procedures, but where possible advice is given when evidence is available. It is noted however, that there has been little new evidence since the last guidelines were published in 2003.
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