Page 11 - JSOM Summer 2023

Risk of Harm in Needle Decompression

for Tension Pneumothorax

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Patrick Thompson *; Angelo Ciaraglia, MD ; Erin Handspiker MD ;
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Christopher Bjerkvig, MD ; James Bynum, PhD ; Elon Glassberg, MD ;
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Jennifer M. Gurney, MD ; Anthony Hudson, MD ; Donald H. Jenkins, MD ;
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Susannah E. Nicholson, MD, MS ; Geir Strandenes, MD ; Maxwell A. Braverman, DO 12
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ABSTRACT
Introduction: Tension pneumothorax (TPX) is the third most The pathophysiology of TPX is secondary to an accumulation
common cause of preventable death in trauma. Needle decom- of air in the pleural space above atmospheric pressure due to
pression at the fifth intercostal space at anterior axillary line an injured lung and the resultant “air leak.” This air leak col-
(5th ICS AAL) is recommended by Tactical Combat Casualty lapses the lung, and the increase in intrapleural and intratho-

Care (TCCC) with an 83-mm needle catheter unit (NCU). racic pressure reduces cardiac output secondary to decreased
We sought to determine the risk of cardiac injury at this site. right atrial filling. This leads to an obstructive shock and re-
Methods: Institutional data sets from two trauma centers sults in cardiac arrest unless aggressively managed. 2
were queried for 200 patients with CT chest. Inclusion criteria
include body mass index of ≤30 and age 18–40 years. Mea- The emergency treatment of this pathology is a thoracentesis,
surements were taken at 2nd ICS mid clavicular line (MCL), usually using a needle, which is known as needle decompres-

5th ICS AAL and distance from the skin to pericardium at sion (NDC). NDC acts to relieve the build-up of pressure in
5th ICS AAL. Groups were compared using Mann-Whitney U the pleural space by allowing gas to escape through the needle
and chi-squared tests. Results: The median age was 27 years and cannula. Two locations are recommended for this pro-
with median BMI of 23.8 kg/m . The cohort was 69.5% male. cedure: a) the 2nd intercostal space at the midclavicular line
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Mean chest wall thickness at 2nd ICS MCL was 38-mm (inter- (2nd ICS MCL), which has been the classic teaching, and b)

quartile range (IQR) 32–45). At 5thICS AAL, the median chest more recently, the 5th intercostal space at the anterior axillary

wall thickness was 30-mm (IQR 21–40) and the distance from line (5th ICS AAL), which is now recommended by Tactical
skin to pericardium was 66-mm (IQR 54–79). Conclusion: The Combat Casualty Care (TCCC) (Figure 1). 3
distance from skin to pericardium for 75% of patients falls
within the length of the recommended needle catheter unit Following concerns that the shorter intravenous (IV) can-
(83-mm). The current TCCC recommendation to “hub” the nula did not have the length required to reach the pleural
83mm needle catheter unit has potential risk of cardiac injury. space, a recommendation was made by the Committee on
TCCC (CoTCCC) to use longer needles. The current TCCC
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Keywords: pneumothorax; needle thoracentesis; battlefield guideline recommendation is “decompress the chest on the
trauma side of the injury with a 14-gauge or a 10-gauge, 3.25-inch
(82.5-mm) needle/catheter unit.” The procedure is described
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as “insert the needle/catheter unit all the way to the hub and
Introduction hold it in place for 5–10 seconds to allow decompression to
occur.” 3
Tension pneumothorax (TPX) is considered one of the three
primary causes of preventable death from trauma, following When performing an NDC on the left using the left lateral 5th
hemorrhage (91%) and airway obstruction (8%), with a mor- ICS AAL, there is a potential for injury to the heart from the
tality of 1.1%. These statistics were obtained from a 10-year initial hubbing of the 83-mm NCU. This risk is likely under-
review of battlefield fatalities published by Eastridge et al. in estimated. To better assess the potential for iatrogenic harm, an
2012. 1 anatomic analysis was designed using cross-sectional imaging
*Correspondence to pat@atem.org.uk
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1 Patrick Thompson is affiliated with the Trauma, Hemostasis & Oxygenation Research Network, Bergen, Norway. Dr Angelo Ciaraglia,

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9 Dr Donald H. Jenkins, and Dr Susannah E. Nicholson are physicians affiliated with the University of Texas Health San Antonio, Division
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of Trauma, San Antonio, TX. Dr Erin Handspiker and Dr Maxwell A. Braverman are physicians affiliated with St. Luke’s University Health
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Network, Bethlehem, PA. Dr Christopher Bjerkvig and Dr Geir Strandenes are physicians affiliated with the Haukeland University Hospital,
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Bergen, Norway and the Norwegian Navy. Dr James Bynum is a scientist affiliated with the U.S. Army Institute for Surgical Reaearch, Joint
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Base San Antonio, San Antonio, TX. Dr Elon Glassberg is a physician affiliated with the Azrieli Faculty of Medicine, Bar-Ilan University, Safed,
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Israel and the Uniformed Services University of the Health Sciences, Bethesda, MD. COL Jennifer M. Gurney is a physician affiliated with the
Joint Trauma System Defense Center of Excellence, San Antonio, TX. Dr Anthony Hudson is a physician affiliated with the Peninsula Trauma
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Network (A.H.), Royal Devon & Exeter NHS Foundation Trust, Exeter, UK.
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