Page 28 - JSOM Summer 2018

After discussion, most of the participants in the teleconfer- FIGURE 3 Clinical photograph from a civilian trauma center
ence favored including both NDC sites without specifying a showing multiple needle decompressions in both the anterior and
preferred site. Further, the 2012 DHB report on needle de- the lateral locations. Note that two of the needles in the anterior site
81
compression of suspected tension pneumothorax in TCCC have been inserted at locations medial to the midclavicular line.
stated that: “No definitive literature was found that estab-
lishes the superiority of the second intercostal space at the
MCL over the fourth or fifth intercostal site at the AAL as the
preferred site for needle decompression of a presumed tension
pneumothorax. 24

Recommendation:
– Either the fifth ICS in the anterior axillary line (AAL) or
the second ICS in the MCL may be used for NDC. If the
anterior (MCL) site is used, do not insert the needle medial
to the nipple line.

Figures 1 and 2 show NDC being performed at the second
ICS in the MCL in a cadaver model. Figures 3 and 4 show
several instances of NDC intended to be at that location being
performed too medially. Figures 5 and 6 show NDC being per-
formed at the fifth ICS at the AAL in a cadaver model.

What is the best needle decompression technique?
As with most medical procedures, the technique used for NDC Photograph courtesy of Dr Warren Dorlac.
may greatly impact the success rate.
FIGURE 1 NDC being performed at the second ICS in the MCL in a
cadaver model.

FIGURE 4 CT scan from a civilian trauma center showing a catheter
that was used to perform needle decompression located in the
myocardium.

Photograph courtesy of LTC Mark Buzzelli.

FIGURE 2 NDC at the second ICS in the MCL with the needle Photograph courtesy of Dr Jay Johannigman.
removed and the catheter left in place in a cadaver model.

The first NDC technique recommendation is to insert the nee-
dle/catheter unit at a 90-degree angle (perpendicular) to the
chest wall. An angulated insertion increases the distance the
needle has to travel through tissue and decreases the likelihood
of entering into the pleural space. If the angulation is cepha-
Photograph courtesy of LTC Mark Buzzelli. the neurovascular bundle at the inferior aspect of the rib above
lad, the likelihood of injuring intercostal vessels traveling in
the intercostal space used may be increased.

Second, the entry point for NDC should be at the superior as-
pect of the lower rib at the insertion site used—again, in order
to avoid the intercostal vessels located at the inferior aspect of

26 | JSOM Volume 18, Edition 2/Summer 2018 the rib above.