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Breathing - Thoracostomy (needle)

Indications

Suspected pneumothorax

and

Low saturations or hypotension (tension pneumothorax)

Contraindications (absolute in bold)

None

Alternatives

Thoracostomy (open)

Small intercostal catheter (Seldinger technique)

Large intercostal catheter (blunt dissection size 24-32Fr)

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Failure to decompress

Pain

Haemorrhage

Neurovascular, visceral and pulmonary parenchymal damage

Occlusion with recurrence of tension pneumothorax (blockage, dislodgement)

Infection

Procedural hygiene

Standard precautions

Standard aseptic non-touch technique

PPE: non-sterile gloves, apron, surgical mask, eye protection

Area

Any area, followed by transfer to resuscitation bay

Staff

Procedural clinician

Equipment

Normal 12-16g IV catheter (5cm)

Long 12-16g IV catheter (8cm)

5-10ml syringe (optional)

Positioning

Sitting up or supine

Medication

Nil

Sequence (primary attempt: normal IV catheter at anterior axillary line)

Palpate anterior axillary line at the lateral border of pectoralis major

Locate mid-arm point (shoulder tip to antecubital fossa) and mark skin at anterior axillary line, or

Place your open hand in the axilla and mark the edge of the hand at the anterior axillary line

Place the patient’s arm out to the side or behind their head (abducted and externally rotated)

Insert needle at intercostal space closest to mark, perpendicular to skin

Advance needle until air is aspirated into a syringe full or water, then remove syringe, or

Advance needle without syringe until gush of air noted

Sequence (secondary attempt: 8cm catheter at second intercostal space midclavicular line)

Palpate medial and lateral head of the clavicle and find the midpoint

Place two fingers below clavicle at midpoint (midclavicular line)

Palpated second intercostal space just below second finger

Feel for third rib below the second intercostal space

Insert needle over the top of the third rib perpendicular to skin

Advance needle until air is aspirated into a syringe full or water, then remove syringe or

Advance needle without syringe until gush of air noted

Sequence (failure)

After two failed attempts, proceed to decompression by open thoracotomy

Post-procedure care

Follow immediately with transfer to resuscitation bay and placement of a chest drain

Repeat procedure if haemodynamic compromise recurs prior to chest drain placement

Provide pain relief

Document procedure after completion of drain (completions, technique, complications)

Tips

A 5cm cannula does not reach pleural space anteriorly in 40% of patients

A 5cm cannula at the fourth or fifth intercoastal space anterior axillary line will reach the pleura in 90% of patients

There is no risk of injury to vital structures from a fully inserted 5cm cannula at the anterior axillary line

Cannulas often kink or block, and the procedure may need to be repeated

Discussion

For average sized patients, chest wall thickness anteriorly is approximately 4cm. With a 5cm needle high rates of failure (40%) are to be expected due to failure to reach the pleura. The chest wall is narrowest at the anterior axillary line, fourth or fifth intercostal space, with failure rates at this point falling to 10%. Available CT study evidence suggests that no injury to vital underlying structures will be caused with a 5cm needle aimed perpendicular to the chest wall at this point regardless of which side (left or right) the needle is placed. We therefore recommend that the primary attempt for needle decompression is a 5cm cannula placed perpendicular to the skin in the fourth or fifth intercostal space at the anterior axillary line.

With an 8cm cannula, nearly 100% will reach the pleural and achieve theoretical decompression. However, the risk of injury to important underling structures increases to 10%. This injury rate is highest at the anterior axillary line (30%). If an 8cm cannula is available, we suggest it should be only be used after failed decompression with a 5cm cannula. The 8cm cannula should be place at the second intercostal space, midclavicular line, to minimise risk of injury. If only longer catheters are available (e.g. 9cm Dwellcath), they should not be inserted past 1cm from hub (8cm).

If decompression is not achieved by two attempts at needle decompression, the proceduralist should proceed to immediate open thoracotomy followed by chest tube placement.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Ambulance Service of NSW. Blunt thoracic trauma. Report HELI.CLI.09. Sydney: ASNSW; 2013. 5pp. Available from: https://sydneyhems.com/resources/policies-and-procedures/

NSW Agency for Clinical Innovation. Consensus guideline: pleural drains in adults. Sydney: ACI; 2016. 55pp. Available from: https://www.aci.health.nsw.gov.au/resources/respiratory/pleural-drains/pleural-drains-in-adults

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