Page 27 - JSOM Summer 2018

Clinic found a success rate of 83% using the 14-gauge, 3.25-in blood return from the catheter, or a large hemothorax is seen
needle recommended by TCCC. The Chen report likewise on the subsequent radiograph, there should be a high suspi-
9
reported no complications from NDC in 88 patients decom- cion for vascular injury. Using the lateral NT placement ap-
pressed with a 14-gauge catheter. 6 proach may help avoid major anterior vascular structures.” 13
In addition to the 3.25-in, 10-gauge needle described here, Several studies have found that prehospital personnel fre-
there are commercially available 11-cm needles intended for quently perform NDC at the anterior site more medially
use in needle decompression. These FDA-approved NDC de- than recommended, putting the heart and great vessels at
vices include the Russell PneumoFix, a 12-gauge, 11-cm de- risk. 2,21 One small study of civilian paramedics found that 8
vice, and the Enhanced Pneumothorax Needle, a 14-gauge, of 18 NDC attempts were performed medial to the MCL.
21
8.6-cm device. Both devices use a Veress-type needle, which Tien and colleagues reported in 2008 that: “Seven NDs were
deploys a blunt-tipped cannula to cover the point of the needle performed on five soldiers for appropriate indications. All of
after it has entered the pleural space. A PubMed search on these were Afghan army soldiers. All seven decompressions
these two devices did not reveal any published studies of their were performed at least 2 cm medial to the midclavicular line.
clinical use. No animal or clinical data was found in this re- No major complications resulting from the NDs were denti-
view to document that an 11-cm needle length is needed (in fied.” The 2015 Inaba study found that Navy corpsmen us-
2
preference to a 3.25-in needle) to reliably decompress a ten- ing a cadaver model were able to locate the lateral NDC site
sion pneumothorax. correctly 78% of the time, but the anterior NDC site correctly
only 18% of the time. These studies have significant implica-
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Other devices proposed for NDC based on animal models of tions for training TCCC students in needle decompression, as
tension pneumothorax include: discussed later in this report.
– the Vygon Catheter, 6,66
– the ThoraQuik device, 73 The lateral site for NDC has been proposed to be safer and/
– a 5-mm laparoscopic trocar, 72 or associated with a higher success rate than the anterior site
– a modified Veress needle, 7,74 and by multiple authors. 13,15,16,18–20,22,31,33,48,67,78 It is recommended as
– the Reactor bladed trochar device. 75 the primary site for NDC in the 10th edition of ATLS. Other
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studies, however, still recommend or describe the use of the
A concern with the use of larger and/or longer devices is that the anterior site for NDC. 6,9,39,66,79
rate of iatrogenic complications may increase. Potentially serious
complications may result from NDC, including injury to intra- The 2013 Harcke report found that less than half (6 of 13) of
thoracic organs such as the heart, pulmonary artery, subclavian the NDC attempts at the anterior site could be seen to have
artery, and lungs. 19,76,77 In addition, serious injuries can occur to actually entered the chest cavity in the 16 combat fatalities
structures outside the thoracic cavity such as the liver or spleen. studied, whereas all (4 of 4) of the NDC attempts at the lat-
There have been no published reports or JTS documentation of eral site were found to have entered the chest cavity. A 2011
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any major procedural complications from NDC in US combat study from the Canadian military found that a higher pres-
casualties from the Afghanistan and Iraq conflicts, but this ob- sure was required to achieve free flow of air through catheters
servation was made while the military was using 14-gauge nee- placed in the fifth ICS at the midaxillary line compared with
dles, initially 5 cm in length and now 8 cm in length. those placed at the second ICS at the MCL. The authors sug-
gested that catheters placed in the lateral site might kink more
easily than those placed at the anterior site but declined to
Recommendation:
recommend one site over the other based on these findings. A
– Decompress the chest on the side of the injury with a recent study using a cadaver model found that the devices left
14-gauge or a 10-gauge, 3.25-in needle/catheter unit. in place after insertion at the lateral position for NDC were
less likely to become dislodged than those left in place at the
What site should be used for NDC? anterior site during combat casualty transport. 71
Complications from attempted NDC are uncommon but have
been documented in published reports from the civilian sector A TCCC Working Group teleconference on this proposed
and may include cardiac tamponade, life-threatening bleeding change was held on 14 December 2017. Despite the published
due to injuries to the pulmonary, internal mammary, subcla- evidence cited above that might be interpreted as favoring the
vian, or intercostal arteries. 13,19,76,77 These complications have lateral site for NDC as the preferred site, there were several
generally resulted from NDC attempts performed at the sec- additional points made during the teleconference:
ond ICS at the MCL, although this observation must be made
with an understanding that the anterior site for NDC was 1. The anterior site has been widely used for NDC during
the primary site recommended for that procedure until very combat operations in Iraq and Afghanistan and there have
recently; the lateral site was used only infrequently for this been no reports of major procedural complications in US
procedure in the past. The authors found no published pro- casualties as a result;
spective trials or retrospective case series designed to compare 2. Contingencies encountered on the battlefield may make it
the complication rate from attempted NDC at the anterior site more advantageous to use either the anterior site or the
(second ICS at the MCL) versus the lateral site (fifth ICS at lateral site, depending on the particular circumstances of a
the AAL.) The 2015 Wernick report noted that: “Significant given casualty scenario, and medics should be able to use
vascular structures located near the second intercostal space either site as required for a specific casualty;
include the internal mammary artery and its branches, subcla- 3. No clinical studies were identified that have examined the
vian vessels, intercostal vessels, and pulmonary arteries. . . . relative safety and success rates of the lateral site as com-
Therefore, if NT placement results in significant immediate pared with the anterior site for NDC.

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