Needle Pleural Decompression

Indications

• tension pneumothorax

Procedure

Anatomic Location

• classically the 2nd intercostal space at the mid clavicular line (ICS2-MCL) is taught as the ideal location for a needle decompression
• new evidence (SRMA) Link to discussion suggests that the 4th -5th ICS at the anterior axillary line (ICS-AAL) has the lowest predicted failure rate of needle decompression with a 5cm angiocatheter.
• New ATLS guidelines (2018+) recommends the 4-5 ICS-mid-axillary line for decompression in adult patients.

Needle

Length

• ATLS recommends a 5 cm (2 inch) angiocatheter. This is safe, does not cause injuries to underlying structures when aimed perpendicularly to the chest wall at the ICS2-MCL and the ICS4-AAL
• Longer catheters (e.g. 8 cm) cause increased risk of injury (9-30%) to underlying structures.
• Shallow angle of entry increases risk of injury.
• consider 3.25 to 4" catheters

Catheter Gauge

• 14G is standard. Larger is better.

Steps

1. Locate the site (2 ICS-MCL or 4-5 ICS-MAL).
2. Sterilize if possible.
3. Attach needle/catheter to syringe. (OPTIONAL)
4. Over an over-the needle catheter (angiocath) at the site, over the rib. Apply negative pressure (IF USING SYRINGE)
5. Once rush of air is detected, advance the catheter and withdraw the needle.
6. Proceed to insert a chest tube) in the 5th ICS at the AAL (for definite management).

Resources

1. Needle Thoracentesis ATLS - YouTube
2. How To: Chest Needle Decompression - YouTube
3. https://bulletin.facs.org/2018/06/atls-10th-edition-offers-new-insights-into-managing-trauma-patients/
4. https://www.itrauma.org/wp-content/uploads/2014/07/Needle-Decompression-Resource-Document-FINAL-Publication-6-28-14.pdf
5. Needle Aspiration of Pneumothorax by the NEJM - YouTube