Needle Thoracentesis

Aka: Needle Thoracentesis, Needle Thoracostomy, Needle Decompression of Thorax, Finger Thoracostomy

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II. Indications

  1. Tension Pneumothorax (or suspected Tension Pneumothorax in a decompensating patient)

III. Precautions

  1. Needle decompression in the second intercostal space, mid-clavicular has significant disadvantages
    1. Chest wall thickness in obese patients results in a high failure rate
    2. Needle placement in the second intercostal space is frequently misplaced too low
  2. Finger Thoracostomy may be preferred over needle decompression
    1. See Resources below

IV. Equipment

  1. Child: Size 14 gauge over the needle angiocatheter (5 cm)
  2. Adult: Size 10 to 14 or 16 gauge over the needle angiocatheter (7.6 cm to 8 cm, 3 inch)
    1. Needle decompression with 5 cm angiocatheter may fail in 50-60% of adults
    2. Some studies suggest use of longer needles (8 cm needles are associated with a 90% success rate in some studies)
      1. Aho (2016) J Trauma Acute Care Surg 80(2): 272-7 +PMID:26670108 [PubMed]
    3. Other studies suggest 5 cm catheters should be sufficiently long to reach the pleural space in most adult patients
      1. McLean (2011) Am J Emerg Med 29(9):1173-7 [PubMed]

V. Preparation

  1. Personal Protection Equipment

VI. Technique: Needle Thoracostomy

  1. Images
    1. needleThoracostomySmall.png
  2. Insertion site
    1. Historical landmark
      1. Second intercostal space (over 3rd rib) immediately below clavicle (parallel to angle of manubrium)
      2. Mid-clavicular line (or nipple line)
    2. Newer proposed landmark
      1. Anterior axillary line at the 4-5th intercostal space (same as for standard Chest Tube placement)
      2. Lowest failure rate (shallow chest depth)
        1. Laan (2016) Injury 47(4):797-804 +PMID:26724173 [PubMed]
  3. Procedure
    1. Insert angiocatheter immediately OVER the 3rd rib mid-clavicular (or over 5th rib anterior axillary)
    2. Advance the needle perpendicular (90 degrees) to skin surface
    3. Signs of needle entering the pleural space
      1. May feel pop as needle enters pleural cavity
      2. Rush of air, blood or other chest contents (wear Personal Protection Equipment)
      3. Vital Signs and clinical status may suddenly improve as Tension Pneumothorax is relieved
    4. On needle entering chest, hold angiocatheter firmly in place and withdraw needle
  4. Post-procedure
    1. Requires Chest Tube placement after initial needle decompression

VII. Technique: Finger Thoracostomy

  1. Indications
    1. Traumatic Arrest or Peri-Arrest in evaulation of intrathoracic injury
  2. Insertion site
    1. Anterior axillary line at the 4-5th intercostal space (same as for standard Chest Tube placement)
  3. Procedure
    1. Perform same procedure as for Chest Tube placement, but instead of inserting Chest Tube, insert finger
    2. Performed bilaterally
  4. Post-procedure
    1. Requires Chest Tube placement after initial needle decompression
    2. May insert Chest Tube over Elastic Bougie

VIII. Resources

  1. Regions Trauma Professional's Blog - Needle decompression (Michael McGonigal, MD)
    1. http://www.youtube.com/watch?v=UvHJ4pjNh2Q
  2. EM-Crit RACC Needle vs Finger Thoracotomy (Scott Weingart, MD)
    1. https://emcrit.org/racc/needle-finger-thoracostomy/

IX. References

  1. Orman and Hicks in Herbert (2018) EM:Rap 18(2): 17-8

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