Needle Thoracostomy: Can we all agree to stop sticking needles in the 2nd Intercostal space?
Image 1: Tension pneumothorax is a clinical diagnosis! But it is sometimes seen first on X-Ray due to CXR capabilities in trauma bays.
EMS calls in with 2-minute ETA for ~20 year old Jane Doe with a GSW to the right chest
JD is an obese female with 2-minute transport time
On arrival, JD’s survey shows that she has an intact airway. She is noted to be screaming profanities on arrival.
However she is having significant respiratory distress, using accessory muscles and is found to have absent breath sounds on the right, with palpation between the sternocleidomastoids and trachea suggesting leftward tracheal deviation.
Vitals: RR: 40, O2: 84% on 15 L NRB, HR 140, BP 80/50, MAP 60
You halt your primary survey to treat a suspected tension pneumothorax
Clinical Question: During my EM clerkship experiences I cared for 5 patients who were hemodynamically unstable or in arrest with GSWs to the chest and presented with needle thoracostomy (NT) to the 2nd intercostal space (ICS) in the Midclavicular line (MCL). However I know that there are times that needle thoracostomy in that location is un-successful.
In an adult hemodynamically-unstable trauma patient with suspected tension pneumothorax, if NT is performed (perhaps prior to chest tube thoracostomy), should NT be performed in the 2nd ICS in the MCL, or the 4th or 5th ICS at the Mid Axillary Line (MAL) or Anterior Axillary Line (AAL)?
Summary of Evidence:
1: Optimal needle length and location:
NT in the 2nd ICS in the MCL with a 5 cm, 14 gauge angio-catheter has previously been the standard of care for initial treatment of presumed tension pneumothorax in trauma, incorporated into ATLS until 2018 both pre-hospital and within hospital(6,12).
A number of studies focused on the unacceptably high failure rates of NT from the late 2000s to early 2010s. Due to the nature of unstable trauma, each of the studies below are retrospective or prospective case series rather than randomized controlled trials, with the number of subjects noted by the study. The case studies all consisted of adult patients, and are generally applicable to a North American population and representative of typical trauma patients (I.E. roughly 80% male predominance of subjects), with few or no exclusion criteria.
Recommendations for needle length supported at least a 4.5 cm and possibly 8 cm needle2. The preferred location has only recently progressed from the 2nd ICS at the MCL to the 5th ICS at the MAL, and finally to the 5th ICS at the AAL
In terms of chest wall thickness (CWT), one study in 2008 of 604 male and 170 female major trauma patients at a trauma center in Canada examined CT imaging and found the mean CWT at the 2nd ICS at the MCL was 3.5 cm, but 9.9-19.3% of men and 24.1-35.4% of women had a CWT > 4.5 cm. They calculated a failure rate of 9.9-35.4% with ideal needle placement of a 4.5 cm needle(12).
However, other studies found the CWT to be much wider, such as a study of 110 adult patients at a US Level 1 trauma center which found the CWT to be 4.5 cm (+/1 1.5 cm) on the left and 4.1 cm (+/-1.4 cm) on the right at the 2nd ICS MCL(8).
The body of evidence settled towards the 4th or 5th ICS at the AAL, bolstered by larger, representative studies such as one including 680 adult trauma patients (mean age 41, 81.5% male), which found the CWT at the 2nd ICS MCL was 1.29-1.34 cm thicker than the CWT at the 5th ICS at the AAL (p<0.001)(5).
2: Success, consensus and complications:
Summarizing 9 case series, a methodologically sound 2015 review concluded the success rate for NT using a standard 4.4 cm angio-catheter at the 2nd ICS in the MCL is 58-75%, with the success rate falling to 50% if an ongoing air leak was present, due to a combination of factors including too short of a needle, incorrect placement, clot/kinking within the catheter, and/or air leak greater than the evacuation rate of the needle(11).
By 2015, a consensus had built that an optimal catheter must be at least 4.5 cm, but that in larger patients a 4.5 cm catheter would fail to aspirate the pneumothorax in >19.3% of men and >35.4% of women(12), and thereby that in larger body habitus patients a longer, 6 or 7 cm catheter11, or even 8 cm needle(2) should be used.
Further concern over the 2nd ICS MCL arose following a (albeit very small) study showing that only 60% (N=15) of emergency physicians correctly identified the 2nd ICS MCL on volunteers, with a location range of error of 3 cm(3). This 3 cm range may be more impactful than a similar error in the 4th or 5th ICS MAL, as the 2nd ICS MCL is surrounded by large vascular structures both superiorly and medially, with the 2nd most common bleeding source follow NT placement being from puncture of lung parenchyma(7). This is partially due to the lung vessels being larger more medial towards the heart (I.E at the MCL vs the MAL or AAL). Several sources therefore recommend the lateral approach to potentially avoid puncturing these structures(1,11).
By 2018, the 10th edition of ATLS, citing the above CWT and the rate of complication of 2nd ICS MCL injury to adjacent vasculature structure, changed the recommendation to the 4th or 5th ICS in the MAL(4). The literature lacked enough evidence and consensus to identify a more specific location such as the 5th ICS in the AAL.
3: Special Cases:
An alternative location should be used in cases of infection over preferred site(11)
Recommendations for children are scarcer, but some studies such as one case series of 139 children age 0-10 recommend the 4th ICS at the AAL for similar reasons as above(9).
Representative case series of hundreds of patients support the ideal NT site for all-comer adult (and less so pediatric) trauma patients with suspected tension pneumothorax as a 14 gauge or greater angiocath that is >4.5 cm or longer for larger body habitus patients.
NT should be performed at the 4th or 5th ICS in the MAL or AAL, with the best location likely the 5th ICS at the AAL due to CWT and better margin of error in nearby structures.
Butler KL, Best IM, Weaver WL, Bumpers HL. Pulmonary artery injury and cardiac tamponade after needle decompression of a suspected tension pneumothorax. The Journal of Trauma: Injury, Infection, and Critical Care: March 2003 - Volume 54 - Issue 3 - p 610-611 doi: 10.1097/01.TA.0000046380.92001.81
Chang SJ, Ross SW, Kiefer DJ. Et al. Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax. J Trauma Acute Care Surg. 2014 Apr; 76(4):1029-34.
Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracentesis. Emerg med J. 2005 Nov;22(11):788-9.
Henry S, ATLS 10th edition offers new insights into managing trauma patients. 2018, Features, Bulletin of the American College of Surgeons.
Inaba K, Ives C, McClure K et al. Radiologic Evaluation of Alternative Sites for Needle Decompression of Tension Pneumothorax. Arch Surg. 2012;147(9):813-818. doi:10.1001/archsurg.2012.751
Netto FA, Shulman H, Rizoli SB. Are needle decompressions for tension pneumothoraxes being performed appropriately for appropriate indications? Am J Emerg Med. 2008 Jun; 26(5):597-602.
Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening hemorrhage after anterior needle aspiration of pneumothorax. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J. 2003 Jul;20(4):383-4.
Stevens RL, Rochester AA, Busko J et al. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7. doi: 10.1080/10903120802471998.
Terboven T, Leonhard G, Wessel L. Chest wall thickness and depth to vital structures in paediatric patients - implications for prehospital needle decompression of tension pneumothorax. Scand J Trauma Resusc Emerg Med. 2019 Apr 16;27(1):45. doi: 10.1186/s13049-019-0623-5
Tupchong K. Update: Is Needle Aspiration Better Than Chest Tube Placement for the Management of Primary Spontaneous Pneumothorax? Annals of Emergency Medicine. July 2018Volume 72, Issue 1, Pages e1–e2 DOI: https://doi.org/10.1016/j.annemergmed.2018.02.025
Wernick B, Hon H, Mubang R et al. Complications of needle thoracostomy: A comprehensive clinical review. Int J Crit Illn Inj Sci. 2015 Jul-Sep; 5(3): 160–169.
Zengerink I, Brink PR, Lauplan KB et al. 2008, Needle Thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008 Jan;64(1):111-4. doi: 10.1097/01.ta.0000239241.59283.03.
Image 1: https://step2.medbullets.com/pulmonary/120665/tension-pneumothorax
Image 2 https://www.earthslab.com/wp-content/uploads/2017/10/Axillary-lines.jpg