From the Guidelines
Needle decompression at the second intercostal space is indicated for emergency management of tension pneumothorax in the prehospital setting, and should be performed with a No. 14 puncture needle (8.25 cm in length) at the second intercostal space in the midclavicular line, as recommended by the Chinese expert consensus on echelons treatment of thoracic injury in modern warfare 1. The procedure should be performed when a patient presents with signs of tension pneumothorax including:
- Respiratory distress
- Decreased or absent breath sounds on the affected side
- Hypotension
- Tachycardia
- Jugular vein distention
- Oxygen desaturation that is not responding to supplemental oxygen The preferred site is the second intercostal space at the midclavicular line on the affected side. After identifying the site, clean with antiseptic solution, insert the needle perpendicular to the chest wall just above the third rib (to avoid neurovascular structures), and advance until a rush of air is heard or felt, indicating successful decompression. Leave the catheter in place and remove the needle. This procedure works by releasing trapped air that is causing mediastinal shift and cardiovascular compromise, allowing for improved venous return to the heart and better cardiac output. The use of ultrasound in the diagnosis of tension pneumothorax has been shown to have high sensitivity and specificity, with a study by Zong et al. finding that the sensitivity and specificity of ultrasound in the diagnosis of tension pneumothorax were 92.0% and 99.4%, respectively 1. Remember that needle decompression is a temporary measure until definitive treatment (typically tube thoracostomy) can be performed at the hospital. It is also important to note that the thickness of the chest wall of individual patients can be more than 5 cm at the second intercostal space, making a longer needle necessary, as recommended by the Committee for Tactical Emergency Casualty Care (C-TECC) 1. The addition of a valve to the end of the puncture needle can also be considered, as it may increase the effectiveness of decompression, especially when the estimated evacuation time is long or the evacuation may be delayed 1.
From the Research
Indications for Needle Decompression
- Needle decompression is a lifesaving intervention for tension pneumothorax, a potentially life-threatening complication of chest trauma 2, 3, 4, 5, 6
- The procedure involves inserting a needle into the chest cavity to relieve increased intrapleural pressure and is recommended in trauma guidelines as an emergency procedure 2, 4, 5
Optimal Anatomical Location
- The optimal anatomical location for needle decompression is a topic of debate, with studies suggesting both the 2nd intercostal space in the midclavicular line (ICS2-MCL) and the 4th/5th intercostal space in the anterior axillary line (ICS 4/5-AAL) as preferred locations 2, 5, 6
- A study found that chest wall thickness (CWT) was significantly thinner in ICS2-MCL compared to ICS4/5-AAL in overweight and obese subjects, suggesting higher theoretical chances of successful needle decompression in ICS2-MCL 2
Needle Length and Decompression Site
- The use of a needle of 7 cm in length is recommended to decompress a tension pneumothorax in the second intercostal space in the midclavicular line, which may successfully decompress more than 90% of patients 4, 5
- A meta-analysis found that increased needle length reduced failure rates by 7.76% per cm and recommended a 7 cm needle for decompression of right-sided tension pneumothorax at either the 5th intercostal space along the midaxillary line or the 2nd intercostal space along the midclavicular line 5
Considerations for EMS
- EMS providers should consider the optimal anatomical location and needle length when performing needle decompression for tension pneumothorax 2, 4, 5, 6
- The potential risk of iatrogenic lesions caused by the proximity of the intended puncture track to the internal mammary artery should also be considered 4