The ND failed to restore perfusion in nine events (64%). Needle decompression and Burping will do nothing to alleviate a Hemothorax. Careers. They make needle decompression kits which typically have the 5 cm angiocath you are looking for. Advanced Trauma Life Support (ATLS) Tips to Be Kept In Mind. Overall, the 5 th ICS AAL was a superior site for needle decompression based on chest wall measurement; Chest wall thickness was thicker at the 2 nd ICS MCL compared to the 5 th ICS AAL (by 0.5cm) As only 16% of patients had chest walls thicker than the standard 5cm needle commonly used. ... with needle decompression, a … An evaluation of tactical combat casualty care interventions in a combat environment. 16. Cautions with axillary approach: • The liver rises into the thoracic cage on the right side, sometimes as high as the 5th intercostal space. The British Thoracic Society has included the axillary approach as an alternative since 1993.12 Furthermore, after completing a study of their own that showed the viability of this alternative site, authors of the Tactical Combat Casualty Care Guidelines revised their guidelines to include the lateral approach as an acceptable alternative.7 There are circumstances in which the 2ICS-MCL may be difficult to access or contraindicated, including a gunshot wound, indwelling Port-A-Cath, AICD, overlying infection or protective body armor. In the second arm, there were 14 tension pneumothoraces with PEA events treated initially with ND. The pressure of 12.8 mm Hg has been documented in animal models as the pressure at which hemodynamic instability develops. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. With the increase in needle length, success of radiographic decompression increased. The TruMan Trauma X pneumothorax manikin also comes supplied with torso inserts for practicing needle decompression in the 5th intercostal space. In the series of studies focusing on ND, a trend of increasing needle length has been seen. Guidelines for the management of spontaneous pneumothorax. Samuel Chang, MD, et al. Needle decompression: 2nd Intercostal Space at the Midclavicular Line (Front) 5th Intercostal Space at the Anterior Axillary line; We can also apply almost any internal or external injury to baby, child or adult SIMBODIES Manikins or actors. Chang SJ, et al. Treatment: Needle decompression. 12. Needle Decompression is not the only way to relieve a tension pneumothorax, remember that simply lifting the seal and "burping" the wound may relieve the trapped air. eCollection 2018 Mar. Results: Due to the high failure rates studies have been done and found out that the chest wall was smallest at the 4th and 5th intercostal space anterior axillary line, thicker at 4th and 5th intercostal space mid axillary line and thickest at 2nd intercostal space mid clavicular line. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. The majority of the aforementioned studies comparing chest wall thickness were based on radiographic measurements alone. 2. Ferrie EP, Collum N, McGovern S. The right place in the right space? J Trauma Acute Care Surg, 2012 Dec; 73(6): 1,412–7. Chest Tube placement is only after the Needle Decompression of Thorax has been completed; Indications for operative management in Traumatic hemothorax. Cancer Patients Visited by Pink Fire Truck, Conn. EMS, Hospitals Coordinate Patient Transport with New Technology, Off-Duty Ohio EMT Delivers Baby in Parking Lot, National Organizations Publish Position Paper on Spinal Motion Restriction, EMS Around the World: The Hungarian National Ambulance Service. There is evidence from computed-tomography and cadaveric studies that the chest wall thickness at these sites may be comparable to the site of anterior approach. Clipboard, Search History, and several other advanced features are temporarily unavailable. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? Using CT scans of 110 patients, it noted that using a standard-size angiocatheter (4.4 cm), needle decompression would be unsuccessful in 50% of trauma patients based on its patient population.15, Kenji Inaba, MD, and colleagues took this idea one step further. 11. 2016 Feb;80(2):272-7. doi: 10.1097/TA.0000000000000889. You start your ATLS exam. Colo. Medics Credit Woman For Saving Husband's Life with CPR, EM Innovations Introduces New Handheld Suction Device, Child’s Play: Scoop-and-Run May Not Be Best for Kids in Cardiac Arrest, Your Captain Speaking: Medication Compliance, Ind. Emerg Med J, 2005 Nov; 22(11): 788–9. Insert the 14 or 16 gauge angiocatheter with needle placed just above the rib, perpendicular to the skin. Arch Surg, 2012 Sep; 147(9): 813–8. A needle decompression involves inserting a large-bore needle into the second or fifth intercostal space to release the trapped air compressing the lung. Second intercostal space, midclavicular line. EMS World is a trademark of HMP. - Other alternative sites for needle decompression include placement at the fourth or fifth intercostal space in the anterior axillary line or at the midaxillary line. A systematic review in Injury 2015 found that in up to 38% of patients a 5cm needle would fail to reach the pleural space in 2ICS MCL. Zong ZW, Wang ZN, Chen SX, Qin H, Zhang LY, Shen Y, Yang L, Du WQ, Chen C, Zhong X, Zhang L, Huo JT, Kuai LP, Shu LX, Du GF, Zhao YF; Representing the Traumatology Branch of the China Medical Rescue Association, the Youth Committee on Traumatology Branch of the Chinese Medical Association, the PLA Professional Committee and the Youth Committee on Disaster Medicine, and the Disaster Medicine Branch of the Chongqing Association of Integrative Medicine. This study suggests that the 14-gauge, 1.5-inch angiocatheter used for ND in the midaxillary line may partially and temporarily occlude in patients who will be transported on military stretchers. • Locate the second (2nd) intercostal space mid- clavicular line, or the fifth (5th) intercostals space mid-axillary line • Prepare the site with aseptic technique using betadine solution (swab) • Insert the needle at the second intercostal space at the mid-clavicular line, directing the needle just over the top of the third rib to avoid the intercostal vessels and nerves. That location is the 5th intercostal space around the mid-axillary line. Butler FK Jr, Holcomb JB, Shackelford S, Montgomery HR, Anderson S, Cain JS, Champion HR, Cunningham CW, Dorlac WC, Drew B, Edwards K, Gandy JV, Glassberg E, Gurney J, Harcke T, Jenkins DA, Johannigman J, Kheirabadi BS, Kotwal RS, Littlejohn LF, Martin M, Mazuchowski EL, Otten EJ, Polk T, Rhee P, Seery JM, Stockinger Z, Torrisi J, Yitzak A, Zafren K, Zietlow SP. This was demonstrated in a two-arm study that created tension pneumothoraces in porcine models until they reached hemodynamic compromise or pulseless electrical activity arrest. Suggested size for adults is 10 gauge x 3.25 inch The shift has been dull until boom!—a call comes over the radio, and suddenly lights and siren are at full blare. You remove the patient’s undergarments and note a gunshot wound to the right parasternal area. J Accid Emerg Med, 1996 Nov; 13(6): 426–7. Sci Rep. 2021 Feb 16;11(1):3874. doi: 10.1038/s41598-021-81225-4. J Trauma Acute Care Surg, 2014 Apr; 76(4): 1,029–34. 10. Hawnwan Philip Moy, MD, is an assistant medical director of the Saint Louis City Fire Department, and emergency medicine clinical instructor and core faculty of the EMS Section of the Division of Emergency Medicine at Washington University in Saint Louis, MO. Tension Pneumothorax (TP) is one of the commonest complication of chest trauma. Thus it was concluded that the lateral approach did not work as well as the anterior approach because the catheters were more likely to be kinked and occlude.1, A 2011 study led by Inaba used 20 randomly selected human cadavers to assess differences in CWT (distance) and ND success (entry intro pleural space) between the 2ICS-MCL and the 5ICS-MAL. An alternative site may be needed. Background: Minerva Pediatr. Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Furthermore, the CWT was statistically greater at the 2ICS-MCL compared to the 5ICS-AAL. As our population becomes more obese, the distance the needle must traverse becomes longer and the concern that the pleural space is not reached is heightened. Decompression of Tension Pneumothorax Tactical Combat Casualty Care Guideline Recommendations 2012-05. Emergency department doctors were below the 5th intercostal space in 64% of cases. The next logical step was to assess the differences in radiographic decompression using a longer needle. You mobilize the monitor and supply bag and wait for the back doors to open to jump out. Stevens RL, et al. Premium torso inserts have three layers for skin, fat and muscle tissue for realistic feel and resistance. For children, a shorter angiocath is appropriate. Some also include a Heimlich valve which is less necessary but nice to have. A tube thoracostomy was performed as a rescue intervention and restored perfusion in eight of the nine NT failures.11. As patients become larger and the standard catheter length remains unchanged, entering the pleural space becomes more difficult, which may lead to failed decompressions and worse outcomes. However, within the last 15–20 years, this has come into question on multiple fronts. For many years the management for tension pneumothorax decompression was the immediate insertion of a wide bore Cather (14-16 gauge) into the 2nd intercostal space (ICS) in mid-clavicular line (MCL) followed by the insertion of a chest tube in the 5th ICS anterior to the mid-axillary line (MAL). This involves using a needle catheter to release the trapped air in the pleural space. 2018 Summer;18(2):19-35. The study concludes that although their evidence suggests a lateral approach, trials with living humans are necessary before a change in practice should be advocated.9, It is often overlooked that the instruments used to decompress a patient with a tension pneumothorax are not primarily designed for this purpose. However, in the CT scanner, the arms are positioned above the head, which stretches and thins the muscles of the chest wall and redistributes breast tissue across the chest. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. His professional interests include medical education, patient-physician dynamics, and EMS critical care. This has come about because shorter needles may not reach the pleural space when inserted under the clavicle in larger patients. * Either the 5th intercostal space (ICS) in the anterior axillary line (AAL) or the 2nd ICS in the mid-clavicular line (MCL) may be used for needle decompression (NDC.) Accessibility Using a 5-cm needle, radiographic decompression was achieved 66%–76% of the time at the 2ICS-MCL and 75%–81% of the time at the 4ICS-AAL. Authors also noted that radiologic noninjury (defined as the distance to a vital structure greater than needle length) rates were higher for the 5-cm needle (99% or higher at all sites) compared to the 8-cm (68%–100% depending on site). Lee CC, Chuang CC, Lu CL, Lai BC, So EC, Lin BS. Economy torso inserts have a single solid layer and are a lower-cost alternative. Turk J Emerg Med. J Special Op Med, 2012; 12(4): 118–22. Chest wall thickness may limit adequate drainage of tension pneumothorax by needle thoracocentesis. An alternative location for emergency needle decompression is via the fifth intercostal space on the midaxillary line. Daniel Charles Kolinsky, MD, is a second-year emergency medicine resident physician at Washington University in St. Louis, and a graduate of Louisiana State University Health Sciences Center. Based on the current evidence, advocating for a change in primary site selection is premature. The needles were secured and thoracotomy was then performed to … J Am Coll Surg. Paramedic use of needle thoracostomy in the prehospital environment. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. Using an 8-cm needle, radiographic decompression achieved success at least 96% of the time independent of the site selected. Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02. Cadaver studies have shown improved success in reaching the thoracic cavity when the fourth or fifth intercostal space mid-axillary line is used instead of the second intercostal space mid-clavicular line in adult patients.