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setting or ‘under fire’, yet there is no haemostatic agent that satis- outcome was confirmed in 17 attempts. In 7 placements, the cath-
fies the seven characteristics of an ‘ideal haemostat’. We conducted eter was in the pleural cavity; in 7 placements, the catheter never
a systematic search of Embase, Medline, the Cumulative Index to entered the pleural cavity; and in 3 placements, cavity penetration
Nursing and Allied Health Literature (CINAHL), and the Web of was verified at autopsy even though the catheter was no longer in
Science to evaluate the feasibility and efficacy of three types of the cavity. Success was noted in 6 of 13 anterior attempts and 4 of
haemostatic devices. Participants included any trauma patient in a 4 lateral attempts, for an overall success rate of 59% (10 of 17).
pre-hospital setting, perfused human cadavers, or healthy human In the remaining 6 attempted procedures, a catheter was noted in
volunteer simulations. The haemostatic devices reviewed were the soft tissue on imaging; however, presence or absence of pleural
REBOA, iTClamp, and four junctional tourniquets: AAJT, CRoC, cavity penetration was equivocal. All placements were attempted
JETT, and SJT. The SJT had the best user survey performance of in the combat environment; no information is available about
the junctional tourniquets, and the four junctional tourniquets specifically where or by whom. Conclusion: NTD via a lateral
had an overall efficacy of 26.6–100% and an application time approach was more successful than that via an anterior approach,
of 10–203 s. The iTClamp had an efficacy of 60–100% and an although it was used in fewer cases. This supports the revisión of
application time of 10–60 s. REBOA had an efficacy of 71–100% the Tactical Combat Casualty Care Guidelines specifying the lat-
and an application time ranging from 5 min to >80 min. In civilian eral approach as an alternative to an anterior approach.
and military trauma patients, with the use of junctional tourni-
quets, iTClamp, or REBOA, mortality varied from 0–100%. All Optimal anatomical location for needle chest
of these studies were deemed low to very low in quality; hence, decompression for tension pneumothorax:
the reliability of data presented in each of the studies is called into a multicenter prospective cohort study
question. We conclude that despite limited data for these devices, N Azizi, E Ter Avest, AE Hoek, Y Admiraal-van de Pas, PJ Buizert,
their use in the pre-hospital environment or ‘under fire’ is feasible DR Peijs, I Berg, AV Rosendaal, T Boeije, V Rietveld, T Olgers, JC
with the correct training, portable imaging, and patient selection Ter Maaten; PRIDE consortium
algorithms. However, higher quality studies are required to con- Injury. 2020;S0020-1383(20)30888-3.
firm the true efficacy of these devices.
Objective: Tension pneumothorax (TP) can occur as a potentially
Studies on the correct length of nasopharyngeal airways life-threatening complication of chest trauma. Both the 2nd inter-
in adults: a literature review costal space in the midclavicular line (ICS2-MCL) and the 4th/5th
Catharina Scheuermann-Poley, MD; André Lieber, MD intercostal space in the anterior axillary line (ICS 4/5-AAL) have
J Spec Oper Med. 21(3):45–50. been proposed as preferred locations for needle decompression
(ND) of a TP. In the present study, we aimed to determine chest
The use of a nasopharyngeal airway (NPA) as an adjunct airway wall thickness (CWT) at ICS2-MCL and ICS4/5-AAL in normal
device can be critically important in emergency medicine. When weight-, overweight-, and obese patients, and to calculate theo-
placed correctly, the device can prevent upper airway obstruction. retical success rates of ND for these locations based on standard
The goal of our review was to learn whether there is scientific ev- catheter length. Methods: We performed a prospective multicenter
idence about the correct length and the insertion depth, and also study of a convenience sample of adult patients presenting in emer-
possible facial landmarks, that can predict the appropriate length gency departments (EDs) of 2 university hospitals and 6 teaching
of the NPA. There has been no real consensus on how to measure hospitals participating in the PRIDE consortium. CWT was mea-
the appropriate tube length for the NPA. Several studies have been sured bilaterally in ISC2-MCL and ISC4/5-AAL with point of care
able to demonstrate correlations between facial landmarks and ultrasound (POCUS), and hypothetical success rates of ND were
body dimensions; however, we did not find any scientific evidence calculated for both locations based on standard equipment used
on this matter. The reviewed studies do not indicate evidence to for ND. Results: A total of 392 patients was included during a
support current recommended guidelines. This could potentially 2-week period. Mean age was 51 years (range, 18–89), 52% were
lead to both military and civilian emergency training programs male, and mean BMI was 25.5 (range, 16.3–45.0). Median CWT
not having the most accurate scientific information for training was 26 [IQR, 21-32] (range, 9-52) mm in ISC2-MCL, and 26 [21–
on anatomic structures and also not having a better overall under- 33] (range, 10–78) mm in ICS4/5-AAL (p < 0.001). CWT in ISC2-
standing of intraoral dimensions. Emergency personnel should be MCL was significantly thinner than ICS4/5-AAL in overweight
taught validated scientific knowledge of NPAs so as to quickly de- (BMI 25-30, p < 0.001) and obese (BMI >30, p = 0.016) subjects,
termine the correct tube length and how to use anatomic correla- but not in subjects with a normal BMI. Hypothetical failure rates
tions. This might require further studies on the correlations and for 45mm Venflon and 50mm angiocatheter were 2.5% and 0.8%
perhaps radiographic measurements. A further approach includes for ICS2-MCL and 6.2% and 2.5% for ISC4/5-AAL (p = 0.016
adjusting the tube to its correct length according to the sufficient and p = 0.052, respectively). Conclusion: In overweight and obese
assessment and management of the airway problem. subjects, the chest wall is thicker in ICS 4/5-AAL than in ICS2-
MCL, and theoretical chances of successful needle decompression
Needle thoracentesis decompression: observations from of a tension pneumothorax are significantly higher in ICS2-MCL
postmortem computed tomography and autopsy compared to ICS 4/5-AAL.
H. Theodore Harcke, MD; Robert L. Mabry, MD; Edward L.
Mazuchowski, MD Paramedic understanding of tension pneumothorax and
J Spec Oper Med. 13(4):53–58. needle thoracostomy (NT) site selection
Jeffrey S Lubin, Joshua Knapp, Maude L Kettenmann
Background: Needle thoracentesis decompression (NTD) is a
recommended emergency treatment for tension pneumothorax. Cureus. 2020;14(7):e27013.
Current doctrine recognizes two suitable sites: the second inter- Introduction: Tension pneumothorax is an immediate threat to life.
costal space in the midclavicular line and the fourth or fifth inter- Treatment in the prehospital setting is usually achieved by needle
costal space in the anterior axillary line. Methods: A review was thoracostomy (NT). Prehospital personnel are taught to perform
conducted of postmortem computed tomography and autopsy NT, frequently in the second intercostal space (ICS) at the mid-cla-
results in 16 cases where NTD was performed as an emergency vicular line (MCL). Previous literature has suggested that emer-
procedure. Results: In 16 cases with 23 attempted procedures, the gency physicians have difficulty identifying this anatomic location

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