Page 72 - Journal of Special Operations Medicine - Fall 2015

What Is the Optimal Device Length and Insertion Site for
Needle Thoracostomy in UK Military Casualties?

A Computed Tomography Study

Georgina Blenkinsop, MBChB; Somayyeh Mossadegh, BM, MRCS;
Mark Ballard, MBBS, FRCR; Paul Parker, FIMC, FRCS(Ed)Orth

ABSTRACT

Significant lessons to inform best practice in trauma decompression, as they were not long enough to fully
care should be learned from the last decade of conflict traverse the chest wall, and enter and remain within the
in Afghanistan and Iraq. This study used radiological pleural space. 7
data collated in the UK Military Hospital in Camp Bas-
tion, Afghanistan, to investigate the most appropriate UK 2013 military Clinical Guidelines for Operations
device length for needle chest decompression of tension (CGOs), which outline best medical practice for the
4
pneumothorax (TP). We reviewed the optimal length of deployed environment, do not currently recommend an
device and site needed for needle decompression of a optimal catheter length to successfully convert a tension
tension pneumothorax in a UK military population and pneumothorax into a simple pneumothorax. A 1996 UK
found no significant difference between sites for needle study used ultrasound to measure the width of the chest
chest decompression (NCD). As a result, we do not rec- wall to measure the minimum length of catheter neces-
ommend use of devices longer than 60mm for UK ser- sary in civilian patients; investigators recommended a
vice personnel. minimum length of 45mm. All recent studies investi-
8
gating device length have been performed in the United
Keywords: decompression, chest; thoracostomy, needle; States and, therefore, results cannot be reliably extrapo-
UK military lated to UK service personnel.

We measured chest wall thickness (CWT) using CT
scans performed on severely injured UK personnel in
Introduction
Camp Bastion over the last 7 years. This allowed us to
Significant lessons should be learned from the wealth deduce the optimal length of device needed for success-
of experience and information collected during the last ful needle thoracostomy.
decade of conflict in Afghanistan and Iraq. These les-
sons should inform best practice in trauma care. This Methods
study used radiological data collated in the UK Military
Hospital in Camp Bastion, Afghanistan, to investigate This is a retrospective survey analyzing consecutive
the most appropriate device length for needle chest de- radiological imaging of UK Service personnel between
compression of TP. Airway injury is the second most 2008 and 2013. This was a registered audit approved by
common of the potentially survivable causes of death in the UK Surgeon General Medical Director. The survey
trauma after hemorrhage. Rapid and effective man- used CT imaging, already held on the UK Joint The-
1–3
agement of TP is paramount in delivering good prehos- atre Trauma Registry database (a database for audit and
pital trauma care. research purposes) to make measurements of CWT to
then analyze.
The first-line management of suspected TP is needle tho-
racostomy. The accepted site of choice in the emergency We surmised that all trauma CT scans performed on
setting is decompression of the pneumothorax at the patients who had additionally received a large-volume
level of the second intercostal space (2ICS) in the mid- blood transfusion represented a severely injured cohort.
clavicular line (MCL), followed by lateral placement if Therefore, the UK Joint Theatre Trauma Registry’s da-
the first site fails. Harcke et al. noted a worrying trend tabase was queried to identify all cases that had trig-
4–6
in computed tomography (CT) imaging in their survey gered the massive transfusion protocol (2008–2013):
of US military postmortem cases; they observed several all cases requiring replacement of an equivalent amount
cases in which catheters were inadequate to achieve of blood to an entire circulating blood volume of the

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