Page 63 - JSOM Winter 2024

the needle has been withdrawn, it should not be re-inserted FIGURE 1 Potential for Iatrogenic harm with misplaced NCU and
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due to risk of cannula shear. This is theoretical risk and, ow- CT of a catheter in the myocardium post needle decompression:
ing to its plausibility, is often a caution, when performing IV Clinical photograph from a civilian trauma center showing multiple
needle decompressions in both the anterior and the lateral locations.
cannulation. The only references to this risk in the literature Note that two of the needles in the anterior site have been inserted at
are related to IV cannulation. locations medial to the midclavicular line.
Injuries of the heart and mediastinal structures are of particular
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concern with needle placements in the left chest. This becomes
of even greater concern when using the larger 14- or 10-gauge,
83mm needle placed to its full length. The authors have wit-
nessed multiple radiographic and anatomic misplacements of
NCU into anatomic structures of the chest to include the heart,
mediastinum, pulmonary artery, and aortic arch. These injuries
have also been reported in the literature. 22–25 It must also be
noted that, due to mediastinal shift in a tension pneumothorax,
if the wrong side of the chest is chosen, the heart will be closer
to the chest wall than in the normal physiological state.

Injury to the great vessels of the chest and intercostal arteries
are potential iatrogenic complications of the NCU. The subcla-
vian arteries and veins may be lacerated if the needle is placed
or directed too superior to the 2nd ICS-MCL. Laterally the
great vessels of the heart (aorta and vena cava) may be dam-
aged as well as the intercostal arteries along the inferior aspect
of each rib.

Perhaps the most commonly witnessed iatrogenic injury dem-
onstrated by NDC is puncture of a normally expanded lung
(a false positive diagnosis and placement). At a minimum, this
creates the potential for an iatrogenic simple pneumothorax. Photograph courtesy of JSOM.
In the worst case, it may create the physiologic conditions
(during positive pressure ventilation) of creating a tension
pneumothorax. The lung may be punctured if the cutting edge
of the needle is advanced past the pleural space, especially if
the incorrect side of the chest is identified or diagnosed as
having the pneumothorax. This also creates the necessity for
placement of a formal chest thoracostomy tube. Finally, there FIGURE 2 CT scan from a civilian trauma center showing a catheter
that was used to perform needle decompression located in the
is suggestion from literature reports that field placement of myocardium.
either NCU or performance of finger thoracostomies increases
the risk of subsequent development of infection in the pleural
space (empyema) in the surviving patient. 19

Finger thoracostomy involves the surgical incision through
superficial tissues, blunt dissection with forceps through the
intercostal muscles, and the insertion of a finger into the pleu-
ral space. The benefits include decompression of the pleural
space should a tension pneumothorax be present and the tac-
tile sensing of the lung to verify movement in response to in-
spiration and expiration. Theoretically the large diameter tract
created during this maneuver could assure a path of air escape
from the pleural space and thus prevent recurrence of tension Photograph courtesy of JSOM.
physiology. As only a gloved finger (which is blunt) is inserted
into the pleural space, there is limited chance for damage. All
efforts should be made to observe aseptic technique. This pro-
cedure is especially recommended in traumatic cardiac arrest.
Studies have found this procedure to be effectively performed
by flight paramedics with limited complications. 19 Occlusive Dressing/Chest Seal
A full-thickness chest wall wound is open for external commu-
Formal chest drain insertion with tube thoracostomy remains nication with the pleural space. Depending on the size of the
the definitive treatment for both simple and tension pneumo- wound opening, atmospheric air can enter the chest in sponta-
thorax. This procedure is usually performed in a hospital set- neously ventilating patients and become trapped in the pleural
ting with surgically trained clinicians or prolonged field care cavity. Theoretically, an open chest wall wound should vent
in a permissive environment. Care must be given to anatomic any intra-pleural air build-up due to an air leak from injured
landmarks, as iatrogenic injury from misplacement is possible. lung or respiratory tree when pressure in the pleural space

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