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Although there is a theoretical advantage to performing NDC performed prior to March 2011 (when 5-cm needles were used
with the casualty in the sitting position, thereby allowing in- for NDC) had a success rate of 41% compared with those who
trathoracic blood to move to a dependent position and air to had NDC after March 2011 (when 8-cm NDC needles began
rise to the most superior location in the pleural space, this to be used), who had a success rate of 83%. Of the 70 patients
maneuver may be difficult to accomplish in a severely injured who underwent NDC procedures, 41 were prehospital and 29
casualty. Sitting upright may be ill-advised in some tactical sit- were in-hospital. No complications were reported with either
uations; it is also contraindicated in casualties with suspected length needle. The site used for NDC in this study was the
spinal cord injury. Finally, moving a casualty who is in shock second ICS at the MCL. Weichenthal and colleagues found
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into the sitting position may decrease blood flow to the brain a 63% rate of clinical improvement in trauma patients not in
and heart. Therefore, most casualties should be positioned su- cardiac arrest who were treated with prehospital NDC using
pine (for anterior or lateral NDC) or in the recovery position needles that were “at least 2 inches long.” 39
(an alternative for lateral NDC) prior to decompression.
Despite the evidence noted above, the use of a 3.25-in needle
has not been universally adopted. Several recent reports de-
Recommendation:
scribe the use of 2-in (or shorter) needles. 65–67 Inaba et al re-
– Place the casualty in the supine or recovery position unless ported that needle decompression at the second intercostal
he or she is conscious and needs to sit up and lean forward space in the midclavicular line using a 5-cm needle would be
to help keep the airway clear as a result of maxillofacial expected to fail in 42.5% of cases, based on CT examinations
trauma. of 680 adult trauma patients. The significant NDC failure rate
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with the shorter needles may have contributed to at least one
What device should be used for needle decompression? report expressing skepticism about the use of NDC to treat sus-
The needle/catheter length recommended prior to 2008 was pected tension pneumothorax: “We found no evidence-based
2 in (4.5 to 5 cm). Davis and colleagues reported a 60% data to support the use of NT (needle thoracostomy) for tension
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success rate for NDC improving the signs and/or symptoms pneumothorax.” 66
of tension pneumothorax when a 14- or 16-gauge needle was
used for the procedure, but they do not specify what length Other studies have proposed the use of needles of intermediate
needle was used. Studies that have used CT exams of chest length between the 5-cm and 8-cm needles discussed above.
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wall thickness have since found that 2-in needles are too A 2015 report from the UK reported a CT study of 63 com-
short to reliably enter the pleural space. 12,17,49,64 Two-inch (or bat casualties and prepared a predicted failure rate of various
shorter) needles have also been associated with NDC failure in lengths of needle at several different sites on the chest wall.
multiple reports 9,12,56,65–67 and should not be used. A failure rate Based on this analysis they recommended that NDC needles
of 80% for prehospital NDC was reported by Kaserer and col- not be longer than 6 cm for UK casualties. A study from Sin-
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leagues. This study mentions that “many emergency medicine gapore recommended a 7-cm catheter based on a CT review
services in our vicinity are using standard venous catheters of chest wall thickness in trauma patients from that region. 48
with a length of 33 mm to 50 mm for chest decompression.” 65
Considering 3.25 in to be the suitable length for needle used
As noted previously, there were at least two US combat-related to perform NDC, attention is next directed to the recommen-
fatalities in the recent Middle Eastern conflicts in which 2-in dation for needle gauge. A 2009 Holcomb study found that a
needles failed to penetrate the chest wall and the casualties 14-gauge needle was just as effective as tube thoracostomy in
died with an unrelieved tension pneumothorax. Both the treating tension pneumothorax in an animal model with an ob-
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US Army and TCCC modified their recommendations for servation period of 4 hours, but other animal models of tension
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NDC to call for a 3.25-in (8-cm) needle shortly after the find- pneumothorax have questioned whether a 14-gauge needle has
ings of Harcke and his coauthors became known. the flow capacity needed to decompress a tension pneumotho-
rax. 7,8,71,72 These seemingly contradictory findings may be due to
There have been no deaths from tension pneumothorax in US variations in the animal models used, especially with respect to
combat casualties attributed to failed needle decompression the amount of blood in the chest cavity, the severity of the ini-
since the US military began aggressively treating suspected tial pleural overpressure, and the amount of air introduced into
pneumothorax with 14-gauge, 3.25-in needles in accordance the pleural space throughout the study to simulate an ongoing
with TCCC Guidelines. The longer needle has also been rec- air leak. Causes of failure in the 14-gauge needle/catheter units
ommended for use in the wilderness setting by Littlejohn. used in these studies included mi gration of the catheter out of the
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The 2013 report by Harcke et al, described seven failures in 13 thoracic cavity, kinking of the catheter after the needle was with-
attempts at NDC when the anterior site for NDC was used. drawn, inadequate flow rate, catheter obstruction with tissue or
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A quote from that study notes: “While the literature has noted clotted blood, and immersion of the needle and/or catheter tip
catheter length to be an important element in failure of needle in blood. 7,8,71,72 The 2017 Leatherman study recommended the
decompression, it was not a factor in our cases. The change use of a 10-gauge needle rather than the currently used 14-gauge
to 8 cm angiocatheters from 5 cm angiocatheters based on needle to address concerns of treatment failure due to inadequate
published chest wall thickness data appears to have eliminated internal needle diameter. The authors of the present review, how-
this cause for an unsuccessful NDT.” The study also does not ever, did not identify any clinical studies in which the safety and
state that any of the 16 combat fatalities included in the report efficacy of 10-gauge versus 14-gauge needles as used for NDC
died solely (or primarily) as a result of an unrelieved tension were compared.
pneumothorax.
Despite concerns raised by the animal model studies noted
A Mayo Clinic retrospective study reviewed 91 NDC pro- above, clinical experience with 3.25-in, 14-gauge needles has
cedures performed on 70 patients. Patients who had NDC been generally favorable. As noted previously, the Mayo
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24 | JSOM Volume 18, Edition 2/Summer 2018