Needle Thoracocentesis - Pneumothorax - Curbside

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Evidence
Total Notes: 3
Evidence

1 Needle Thoracocentesis

Needle thoracocentesis can be a lifesaving procedure in patients with an acute tension pneumothorax. In most cases of tension pneumothorax tube thoracostomy is preferred as it is the definitive therapy, however if there is urgent hemodynamic instability a needle thoracocentesis should be performed immediately. If the patient does not have a pneumothorax, there is a 10 - 20 % chance of causing a pneumothorax with attempt at thoracocentesis. In addition, there is a risk of significant, life-threatening bleeding if the needle is not place properly.



References:
  1. Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs. British Thoracic Society Research Committee.
    Harvey J, Prescott RJ.
    BMJ. 1994 Nov 19;309(6965):1338-9.
  2. BTS guidelines for the management of spontaneous pneumothorax.
    Henry M, Arnold T, Harvey J; Pleural Diseases Group, Standards of Care Committee, British Thoracic Society.
    Thorax. 2003 May;58 Suppl 2:ii39-52.
  3. Diagnosis and treatment of primary spontaneous pneumothorax
    Shi-ping L.
    J Zhejiang Univ Sci B. Oct 2010;11(10): 735–744.
  4. Iatrogenic pneumothorax: etiology and morbidity. Results of a Department of Veterans Affairs Cooperative Study.
    Sassoon CS, Light RW, O'Hara VS, Moritz TE.
    Respiration. 1992;59(4):215-20.
  5. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax.
    Rawlins R, Brown K, Carr C, Cameron C.
    Emerg Med J. Jul 2003;20(4): 383–384.
  6. Complications associated with thoracocentesis.
    Seneff MG, Corwin RW, Gold LH, Irwin RS.
    Chest. 1986 Jul;90(1):97-100.
  7. Intercostal artery laceration following thoracentesis.
    Yacovone ML, Kartan R, Bautista M.
    Respir Care. 2010 Nov;55(11):1495-8.
  8. Needle thoracostomy in the prehospital setting.
    Eckstein M, Suyehara D.
    Prehosp Emerg Care. 1998 Apr-Jun;2(2):132-5.
  9. Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
    Blaivas M.
    J Ultrasound Med. 2010 Sep;29(9):1285-9.
  10. Needle thoracostomy may not be indicated in the trauma patient.
    Cullinane DC, Morris JA Jr, Bass JG, Rutherford EJ.
    Injury. 2001 Dec;32(10):749-52.

2 Needle location

A significant number of providers have difficulty identifying the 2nd intercostal space. In many patients the first rib is not palpable under the patient's clavicle. It has been recommended to start at the midclavicular clavicle and palpate downwards to identify the correct space.



References:
  1. The right place in the right space? Awareness of site for needle thoracocentesis.
    Ferrie EP, Collum N, McGovern S.
    Emerg Med J. 2005 Nov;22(11):788-9.

3 Needle depth

An ultrasound study looking at the depth of the chest wall in 18 - 55 year old patients found that the mean was 3.2 cm (range 1.3 to 5.2 cm). 57 percent had chest walls greater than 3 cm and 4 percent greater than 4.5 cm. In a CT study (mean age 43.5 years), the chest wall mean on the right was 4.5 cm (+/- 1.5 cm) and on the left was 4.1 cm (+/- 1.4 cm).

Because of the chest wall depth measurements if needle thoracocentesis is unsuccessful with a 4.5 cm cannula, a longer needle should be attempted.



References:
  1. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure.
    Britten S, Palmer SH, Snow TM.
    Injury. 1996 Jun;27(5):321-2.
  2. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography.
    Stevens RL, Rochester AA, Busko J, Blackwell T, Schwartz D, Argenta A, Sing RF.
    Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7.
  3. Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan.
    Yamagiwa T, Morita S, Yamamoto R, Seki T, Sugimoto K, Inokuchi S.
    Injury. 2012 Jan;43(1):42-5.
  4. Determination of the appropriate catheter length and place for needle thoracostomy by using computed tomography scans of pneumothorax patients.
    Akoglu H, Akoglu EU, Evman S, Akoglu T, Altinok AD, Guneysel O, Onur OE, Eroglu SE.
    Injury. 2013 Sep;44(9):1177-82.
  5. Average chest wall thickness at two anatomic locations in trauma patients.
    Schroeder E, Valdez C, Krauthamer A, Khati N, Rasmus J, Amdur R, Brindle K, Sarani B.
    Injury. 2013 Sep;44(9):1183-5.