Altered Site for Needle Decompression of Tension Pneumothorax

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November 21, 2012 by dailybolusoflr

A recent JAMA article out of USC+LAC Medical Center investigated an alternative site for needle decompression in tension pneumothorax from the standard 2nd intercostal space (ICS) at the mid-clavicular line. Using CT scans in 680 trauma patients, they compared the 2nd ICS MCL to the 5th ICS at the anterior axillary line (AAL) using a 5-cm decompression needle. They found the 5th ICS AAL was 1.3 cm thinner on average. They calculated the standard decompression needle would fail to penetrate the pleura 42.5% of the time at the 2nd ICS MCL versus 16.7% at the 5th ICS AAL. They also found a step-wise increase in chest wall thickness with increasing BMI and an expected high rate of failure in both groups for BMIs >30.
For many years, ATLS has taught placing a 5-cm decompression needle in the 2nd ICS MCL was an essential step to save a life from tension pneumothorax. This study strongly contradicts this previously accepted method. Keep an eye out for more studies to validate these findings. Clinical studies will need to be done to validate this paper’s findings before this can become a practice changer. Additionally, rates of cardiac injury from left sided 5th ICS AAL decompression need to be analyzed.
5th IC Space Chest Wall
2nd IC Space Chest Wall 

Courtesy of Dr. Ryan Circh

Reference:

Radiological evaluation of alternative sites for needle decompression of tension pneumothorax.
Inada K, Ives C, McClure K, Branco BC, Eckstein M, Shatz D, Martin MJ, Reddy S, Demetriades D. Arch Surg. 2012 Sep; 147(9):813-8

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