What is the procedure for decompressing a traumatic tension pneumothorax in Australia?

From the Guidelines

To decompress a traumatic tension pneumothorax in Australia, immediately perform needle thoracostomy using a large-bore (14-16 gauge) cannula, specifically a No. 14 puncture needle (8.25 cm in length), at the second intercostal space in the midclavicular line, as recommended by the Committee for Tactical Emergency Casualty Care (C-TECC) 1. This procedure is crucial in releasing trapped air that is causing mediastinal shift, compromised venous return, and respiratory distress, thereby converting a life-threatening tension pneumothorax into a simple pneumothorax. The signs for identifying tension pneumothorax include history of chest injury, progressive difficulty breathing, attenuated or absent breath sound on the side of the injury, elevated chest wall on the side of the injury, and hypotension and shock induced by tachycardia and shortness of breath 1. Some key points to consider when performing needle thoracostomy include:

• Insert the cannula at the 2nd intercostal space in the mid-clavicular line, or alternatively at the 4th/5th intercostal space in the mid-axillary line.
• Advance the needle over the top of the rib (to avoid neurovascular structures) until you feel a "pop" and hear air escaping, then remove the needle while leaving the plastic cannula in place.
• If conditions allow, a valve can be added at the end of the puncture needle to increase the effectiveness of decompression 1. Following decompression, it is essential to:
• Arrange urgent chest tube insertion (typically 28-32 French) and transfer to a facility with thoracic surgical capabilities if needed.
• Closely monitor the patient after decompression, as the cannula may become blocked or dislodged, requiring repeat decompression. In the Australian context, paramedics and emergency physicians are typically trained in this procedure, and it's considered standard practice in trauma management protocols 1.

From the Research

Procedure for Decompressing a Traumatic Tension Pneumothorax in Australia

The procedure for decompressing a traumatic tension pneumothorax involves several steps and considerations, as outlined in the following points:

• Needle Decompression: This is a life-saving invasive procedure that every emergency physician or intensivist must master 2. It is recommended to use a needle of at least 5 cm length for decompression 3.
• Technique: The methods available are needle decompression or thoracentesis via mini-thoracotomy with or without insertion of a chest tube in the midclavicular line of the 2nd/3rd intercostal space (Monaldi-position) or in the anterior to mid-axillary line of the 4th/5th intercostal space (Bülau-position) 2.
• Catheter Length: The length of the catheter used for needle decompression is crucial, with studies suggesting that a 4.5-cm catheter is more effective than a 3.2-cm catheter 4. A study also recommends using a needle of 7 cm in length to decompress a tension pneumothorax in the second intercostal space in the midclavicular line 5.
• Complications: Complications are common and mainly include ectopic positions, which can jeopardize the effectiveness of the procedure, sometimes fatal injuries to adjacent intrathoracic or - in case of too inferior placement - intraabdominal organs as well as hemorrhage or infections 2.
• Follow-up: After needle decompression, a chest tube should be inserted, and the patient should be evaluated with a clinical examination, chest X-ray, and sonography, with computed tomography (CT) being the gold standard of diagnostic testing 3.
• Chest Tube Insertion: A small-bore chest tube (e.g., 14 French) should be used in stable patients, while unstable patients should receive a large-bore drain (24 French or larger) 3.
• Therapy: Therapy should be carried out with mild suction of approximately 20 cmH2O, and clamping the chest tube before removal showed no beneficial effect 3.

Key Considerations

• The procedure should be performed without delay in urgent cases 2.
• The choice of technique and catheter length depends on the patient's condition and the availability of equipment 2, 3, 4.
• Complications can be minimized by respecting the basic rules for safe chest decompression and using the correct technique and equipment 2.