Page 82 - JSOM Summer 2024

tracheal deviation, subcutaneous emphysema, mediastinal em- Conclusion
physema, and cardiovascular collapse. 1
Tension pneumothorax has a multitude of causes but ulti-
mately requires emergent procedural intervention. Resusci-
First, when performing a needle thoracostomy, identify the
proper site for needle catheter insertion. Use a 10- to 14-gauge tation will likely be required prior to obtaining a definitive
3.25-inch needle and locate the 2nd ICS midclavicular line diagnosis. The patient in our case is unique because his injury
(MCL)—an imaginary line from the middle of the collarbone. led to suspicion of a tension pneumothorax, but the interven-
The interspace inferior to the clavicle is the 1st ICS. The alter- tion led to a dangerous complication. Furthermore, the needle
native primary site includes the 4th–5th ICS, the midaxillary decompression was performed in a prehospital environment
to anterior axillary line (AAL). Placement should not be infe- where training and education on the procedure are hard to
4
rior to the 5th ICS, to reduce the risk of injuring vital organs evaluate. Our case illustrates the importance of needle decom-
in the superior abdomen. When inserting the needle, it should pression technique training before operative intervention and
be perpendicular to the patient’s chest wall while also listen- emphasizes that, if done incorrectly, needle decompression
ing or feeling for any air exchange in the needle. Once air or could result in life-threatening complications.
blood is elicited through the catheter, do not further advance
the needle. The catheter should be advanced into the pleural Author Contributions
5
space. This decreases the risk of penetrating underlying or- KD and JO conceived the idea of the case report. KD, JO, and
gans and vessels. It has been shown that in 75% of older mil- BR wrote the first draft. All authors reviewed and edited the
itary patients, the distance from the skin to the pericardium manuscript.
falls within the recommended needle length (3.25 inches) for
performing a needle decompression. 6 Disclosures
The authors indicate they have no financial relationships rele-
vant to this article to disclose.
Most deployed U.S. military personnel undergo predeploy-
ment Tactical Combat Casualty Care (TCCC) training as per
OPNAV Instruction 1500.86 and DoD Instruction 1322.24. Funding
7,8
Often, emphasis on the nuances of performing needle decom- No funding was received for this work.
pression is lacking. While most customary TCCC training
involves training failures that allow trainees to bury needle References
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decompression catheters to the hub, it does not impart the streich A. Needle thoracotomy in trauma. Mil Med. 2015;180(12):
knowledge of underlying anatomy and effective assessment of 1211–1213. doi:10.7205/MILMED-D-14-00730
the intervention. 6,9 2. Faizi Z, Morales J, Hlopak J, Batool A, Ratnaseke A. Cardiac
tamponade secondary to iatrogenic needle decompression in
The current Committee on TCCC (CoTCCC) clinical practice blunt force trauma. Proc (Bayl Univ Med Cent). 2022;35(4):524–
guidelines for performing a needle thoracostomy for suspected 525. doi:10.1080/08998280.2022.2063628
tension pneumothorax reaffirm decompression of the injured 3. Ray J, Exantus N. Needle decompression of tension pneumoperi-
toneum: a case report. Clin Pract Cases Emerg Med. 2021;5(4):
side with a 14- or 10-gauge, 3.25-inch needle/catheter that 511–514. doi:10.5811/cpcem.2021.8.53447
may be placed at the 5th ICS AAL or 2nd ICS MCL. If the 4. Craig GK. Special Operations Forces Medical Handbook. 2nd ed.
anterior MCL site is used, do not insert the needle medial to U.S. Special Operations Command; 2008.
10
the nipple line. A randomized study, which included 25 US 5. Laan DV, Vu TD, Thiels CA, et al. Chest wall thickness and decom-
Navy Hospital Corpsmen performing 100 needle decompres- pression failure: a systemic review and meta-analysis comparing
sions on 25 cadavers, determined the 5th ICS AAL as the ideal anatomic locations in needle thoracostomy. Injury. 2016;47(4):
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site for localization and decompression with higher accuracy 6. Thompson P, Ciaraglia A, Handspiker E, et al. Risk of harm in
11
than the traditional 2nd ICS MCL. It is likely that this spe- needle decompression for tension pneumothorax. J Spec Oper
cific patient would have avoided cardiac injury with the 5th Med. 2023;23(2):9012. doi:10.55460/ZU1D-3DL9
ICS AAL approach. 7. Department of Defense. Medical Readiness Training. DoD In-
struction 1322.24; 2011.
While no evidence has proved one site to be more effective 8. Department of the Navy. Tactical Combat Casualty Care Train-
than the other, it is worth identifying the benefits of choosing ing. OPNAV Instruction 1500.86. Office of the Chief of Naval
Operations; 2011.
the 4th and 5th ICS. Most patients have less adipose tissue 9. Anonymous A. Tactical Combat Casualty Care (TCCC) guide-
and muscle along the serratus anterior, which allows for easier lines for medical personnel 15 December 2021. J Spec Oper Med.
access to the ICS. Another benefit is the reduced penetration 2022;22(1):11–17. doi:10.55460/ETZI-SI9T
depth of the needle catheter into the ICS to relieve the under- 10. Butler KL, Best IM, Weaver WL, Bumpers HL. Pulmonary artery
lying pneumothorax. In a combat environment, body armor injury and cardiac tamponade after needle decompression of a
6
represents an obstacle in accessing the 2nd ICS MCL, whereas suspected tension pneumothorax. J Trauma. 2003;54(3):610–
611. doi:10.1097/01.TA.0000046380.92001.81
there is less interference from body armor overlying the 5th 11. Inaba K, Karamanos E, Skiada D, et al. Cadaveric comparison
ICS AAL. Choice of the 5th ICS AAL alleviates the need to re- of the optimal site for needle decompression of tension pneumo-
move body armor, thus reducing ballistic integrity on the bat- thorax by prehospital care providers. J Trauma Acute Care Surg.
tlefield. Trained providers should be adequately competent in 2015;79(6):1044–1048. doi:10.1097/TA.0000000000000849
performing the needle thoracostomy at both sites. Awareness 12. Chen J, Nadler R, Schwartz D, Tien H, Cap A, Glassberg E.
that using the 4th and 5th ICS is the ideal site for tubal tho- Needle thoracostomy for tension pneumothorax: the Israeli De-
fense Forces experience. Can J Surg. 2015;58(3):S118–S124. doi:
racostomy insertion should reaffirm the effectiveness of chest 10.1503/cjs.012914
decompression at this anatomical site. However, there is no
indication to place a tubal thoracostomy in the 2nd ICS to PMID: 38788225; DOI: 10.55460/Y6RW-XWF2
definitely treat a tension hemopneumothorax. 12

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