How to perform a needle decompression for a tension pneumothorax
- Ensure patient is oxygenated if possible
- Select proper site; affected side at the second intercostal space and along the mid-clavicular line. ...
- Clean site with alcohol or povidone solution
- Prepare needle; if it has a leur-lock or flash chamber, it will need to be removed
How do you use a needle decompression?
A needle decompression should only be performed if the patient has a tension pneumothorax. When inserting the needle, it should be inserted at a 90-degree angle to the chest wall. This is a critical point as this will position the needle straight into the pleural space.
What is the site for a needle chest decompression?
The site for a needle chest decompression is the second intercostal space on the midclavicular line, just lateral to the nipple line. It is important to insert the catheter laterally in relation to the nipple line to ensure that you stay outside of the cardiac box (which holds a lot of really important vessels).
What is needle decompression for pneumothorax?
This involves using a needle catheter to release the trapped air in the pleural space. If the patient has either a closed or open tension pneumothorax, then the need for a needle decompression is required to save the patient. A needle decompression involves inserting a large bore needle in the second intercostal space, at the midclavicular line.
Where do you put a needle in a chest xray?
Insert the needle into the second intercostal space at a 90-degree angle to the chest, just over the third rib. Note: There are blood vessels running along the bottom of the ribs. Ensure the needle is closer to the top margin of the lower rib in the intercostal space.
Where do you place needle decompression?
Needle thoracocentesis is a life saving procedure, which involves placing a wide-bore cannula into the second intercostal space midclavicular line (2ICS MCL), just above the third rib, in order to decompress a tension pneumothorax, as per Advanced Trauma Life Support (ATLS) guidelines.
Where do you decompress a tension pneumothorax?
Abstract. Background: A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5-cm (2-inch) catheter (5-cm needle).
Where is needle inserted for pneumothorax?
Key anatomy. Needle aspiration of pneumothorax is done with a needle inserted anteriorly into the 2nd intercostal space on the side of the pneumothorax. The patient should be positioned in a semi-recumbent position to allow air to collect at the apex of the lung.
Which intercostal space is determined for needle decompression?
The most common alternative locations for needle decompression include the fourth (ICS4) and fifth (ICS5) intercostal spaces at both the anterior axillary line (AAL) (ICS4/5-AAL) and the midaxillary line (MAL) (ICS4/5-MAL).
Can you needle decompress a hemothorax?
Needle decompression would be the correct intervention for a pneumothorax, but it would not effectively treat a hemothorax because the caliber of an angiocath would be much too small to effectively drain blood out of the chest — the flow would be so slow that there would be no impact on the tension physiology, even if ...
What is the intercostal space for pneumothorax?
If pneumothorax is under tension or reaccumulates following needle aspiration, the insertion of a chest tube (CT) will be necessary. Appropriate insertion sites include the fourth, fifth or sixth intercostal spaces in the anterior axillary line. The nipple is a landmark for the fourth intercostal space.
Which intercostal space is entered for a thoracentesis?
Procedure-technique-equipment-position Some sources recommend the mid-axillary line in the 6th, 7th, or 8th intercostal space. It is critical that the patient hold his or her breath to avoid piercing of the lung. The pleural fluid collection is located and marked under real-time ultrasound guidance.
What is the landmark for thoracentesis?
The thoracentesis site should be in the mid scapular or posterior axillary line (6-10 cm lateral to spine), and one to two intercostal spaces below the highest level of the effusion.
Is tension pneumothorax open or closed?
Pneumothorax (air in the pleural cavity) is classified as open (external wound) or closed. The pleural pressure equilibrates with atmospheric pressure, resulting in lung collapse. Tension pneumothorax develops when air continuously enters the chest without evacuation.
When do you use needle decompression vs chest tube?
Needle thoracostomy is indicated for emergent decompression of suspected tension pneumothorax. Tube thoracotomy is indicated after needle thoracostomy, for simple pneumothorax, traumatic hemothorax, or large pleural effusions with evidence of respiratory compromise.
What's the difference between a tension pneumothorax and a simple pneumothorax?
Pneumothoraces can be classified as “simple” or “tension.” A simple pneumothorax is non-expanding. In a tension pneumothorax, a “one way valve” defect allows air into but not out of the pleural space. If left untreated, increasing pressure starts to collapse vascular structures within the mediastinum.
How can you tell the difference between pneumothorax and tension pneumothorax?
Pneumothorax is when air collects in between the parietal and viscera pleurae resulting in lung collapse. It can happen secondary to trauma (traumatic pneumothorax). When mediastinal shifts accompany it, it is called a tension pneumothorax.
Where is the most likely insertion site for a nipple?
Depending on the casualty’s age and girth, the most likely insertion site there will be along the anterior axillary line and lateral to the nipple. Both sites are good and equally usable, so don’t think of them in terms of primary and secondary choices.
How long should a 14 g catheter be?
You also need to keep in mind that the first rib lies under the clavicle. Use a large bore, 10 G to 14 G catheter at least 3.25 inches (ca. 8 cm) long to decompress the chest. Clean the site with alcohol swipes, insert the needle using the third rib as a backboard.
How long to wait to remove catheter from pleural cavity?
Once in the pleural cavity, advance the needle down to the hub, wait 10 seconds, then remove the needle while leaving the catheter in the body. Check the patient for signs and symptoms of relief.
Why put chest seal back on?
Then put the chest seal back on so air can no longer enter the pleural space through the wound site.
Can you insert a catheter through a chest seal?
Do not insert the catheter through a chest seal covering the site you’ve chosen for the NCD. Instead, slightly roll the edge of the chest seal enough to make room for the NCD. If you’re unsure whether you can make it work at that particular location, chose a different site.
Can you perform chest decompression multiple times?
Conclusion. In some instances, it will be necessary to perform needle chest decompression multiple times on the same casualty, as time allows. Multiple attempts become necessary when the catheter kinks, becomes obstructed by a clot, or in some other way fails to serve its intended purpose.
What gauge needle is used for trauma resuscitation?
The traditional large bore needle is 14 gauge, but they tend to be short and flimsy. They may not penetrate the pleura in an obese patient, and will probably kink off rapidly. Order the largest, longest angiocath possible and stock them in your trauma resuscitation rooms.
How to treat tension pneumothorax?
The final tip to treating a tension pneumothorax is that a chest tube must be placed immediately after inserting the needle. If the patient is on a ventilator, the positive pressure will slowly expand the lung. But if they are breathing spontaneously, the needle will change the tension pneumothorax into a simple open pneumothorax. Patients with other cardiovascular problems will not tolerate this for long and may need to be intubated if you dawdle.
What does the arrow point to in the trachea?
The arrow points to the completely collapsed lung. Note the trachea bowing to the right.
Where is the 5th intercostal space?
The ATLS course now adds a consideration to use an alternative site. That location is the 5th intercostal space around the mid-axillary line. This has come about because shorter needles may not reach the pleural space when inserted under the clavicle in larger patients. The new spot is the typical location for placement of the inevitable chest tube that has to be inserted after needle decompression.
Where was the EMS video filmed?
This video was likely filmed in an operating room, which is a well-controlled environment, on a patient who was likely intubated and a thoracoscope was used for recording purposes. This environment does not mimic the prehospital world and likely has resources that most EMS services do not have available.
How long do you have to leave a tube in after a thoracostomy?
Chest tubes are typically left in place for several days to up to a week to ensure pneumothoraces have resolved completely.
How long is the video of the thoracic cavity?
The video is very high-quality, is less than two minutes long and was apparently recorded by a Dr. Oleksandr Linchevskyy, described as a Thoracic Surgeon who practices in the Ukraine. At about 20 seconds the glistening parietal pleura lining the inside of the thoracic cavity is clearly visible. A small blob of lung collapsed in the bottom portion of the screen is rising up and down with ventilation, glistening with its own visceral pleural covering, is discernable.
Can an EMS provider decompress a pneumothorax?
EMS providers should NOT expect rapid and complete resolution of the pneumothorax or full re-expansion of the lung when placing an angiocath to decompress a tension pneumothorax. After watching this video one might get the idea that all you have to do is place an angiocath and within 60 seconds the lung is completely inflated again and all is well.
Where is the needle placed for a thoracostomy?
Neurovascular bundles are located at the lower edge of each rib. Therefore, the needle must be placed over the upper edge of the rib to avoid damage to the neurovascular bundle. Rib Anatomy.
Where to insert needle in hemithorax?
The preferred insertion site is the 2nd intercostal space in the mid-clavicular line in the affected hemithorax. However, insertion of the needle virtually anywhere in the correct hemothorax will decompress a tension pneumothorax.
What is needle thoracostomy?
Needle thoracostomy is insertion of a needle into the pleural space to decompress a tension pneumothorax. Needle thoracostomy is an emergency, potentially life-saving, procedure that can be done if tube thoracostomy cannot be done quickly enough.
Where to inject lidocaine?
There is rarely time to provide local anesthesia, but if there is, inject 1% lidocaine into the skin, subcutaneous tissue, rib periosteum (of the rib below the insertion site), and the parietal pleura. Inject a large amount of local anesthetic around the highly pain-sensitive periosteum and parietal pleura. Aspirate with the syringe before injecting lidocaine to avoid injection into a blood vessel. Proper location is confirmed by return of air in the anesthetic syringe when entering the pleural space.
Is needle thoracostomy contraindicated?
Contraindications to Needle Thoracostomy. None. There are no contraindications because this procedure is only done because of an immediate threat to life which supersedes other considerations.
Where Do You Put The Needle For Tension Pneumothorax?
There have many debates about the anatomical location and length of the needle because of the failure rate associated with needle thoracostomy in tension pneumothorax.
Where should a needle be placed on the lower rib?
Therefore the needle must be placed close to the upper edge of the rib in that intercostal space.
What needle is used for pneumothorax?
Needle thoracostomy is done in patients who present with tension pneumothorax as a lifesaving procedure. The usual practice was to use 14-16 gauge needle (an-over the needle catheter is best), the length was 5cm. The anatomical location to insert the needle was 2nd intercostal space mid clavicular line. Due to the high failure rates studies have been done and found out that the chest wall was smallest at the 4th and 5th intercostal space anterior axillary line, thicker at 4th and 5th intercostal space mid axillary line and thickest at 2nd intercostal space mid clavicular line. When an 8cm needle was used the injuries were high. Therefore, these studies suggest the best anatomical location is the 4th or 5th anterior axillary line with a 5 cm needle.
What is the failure rate of a 5 cm needle thoracostomy?
Recent studies have showed that there is a failure rate of 50-75% of needle thoracostomy when a 5 cm needle is used in the 2nd intercostal space mid clavicular line. The recent for this failure has been studied in clinical studies. These studies found out that the chest wall was smallest at the 4th and 5th intercostal space anterior axillary line, thicker at 4th and 5th intercostal space mid axillary line and thickest at 2nd intercostal space mid clavicular line. The reason for needle thoracostomy failure is due to the thick chest wall at the 2nd intercostal space mid clavicular line, therefore a 5cm needle could not reach the pleural space. Studies also have done using different length needles and 8cm needle was commonly used. However, there was high injury rate with the 8cm needle (9%).
Why is my thoracostomy needle not reaching the pleural space?
The reason for needle thoracostomy failure is due to the thick chest wall at the 2nd intercostal space mid clavicular line, therefore a 5cm needle could not reach the pleural space. Studies also have done using different length needles and 8cm needle was commonly used.
What should be considered when performing a needle thoracostomy?
Doctors suggest when performing a needle thoracostomy the patient’s BMI, chest wall thickness should also be considered. The needle length and the anatomical location for the needle placement should be decided wisely.
How far should a throacostomy needle be inserted?
Insert the throacostomy needle, closer to the upper edge of the rib (if the needle is inserted in the 2nd intercostal space then it should be closer to the 3rd rib) at an angle of 90 degrees until a “pop” sound is heard or there is sudden decrease in resistance.
What is needle decompression?
A needle decompression is one of the few procedures you can perform that will often result in an immediate improvement of symptoms.
How to relieve tension pneumothorax?
Needle Decompression is not the only way to relieve a tension pneumothorax, remember that simply lifting the seal and "burping" the wound may relieve the trapped air. This is especially true with larger holes that were actively sucking air in prior to chest seal placement.
Why is the catheter in the air pocket?
Catheter may be advanced too far and its distal opening may be in contact with lung tissue preventing it from evacuating air, backing it out slowly may seat it in the air pocket and facilitate decompression.
What to do if you haven't used chest seals?
If you haven't utilized your chest seals, then that should be the prompt to double-check for any holes that need to be sealed up, remembering to seal all holes regardless of size from the navel to the neck 360 degrees.
How to apply chest seal?
When applying a chest seal use a band-aid technique, peel only a small portion of the back, affix it to the area, and pull the backing away. Newer style seals are extremely sticky, if you peel the entire back off they will likely stick to your hand, gloves, anything else that it comes in contact with it.
Can a non-medic carry multiple needles?
Increased risk of infection. If removed carefully it could potentially be used multiple times, keeping in mind that non-medics typically don't carry multiple needles. Using your only catheter once would require a non-medic to have to do subsequent decompressions with only a needle, thus increasing patient risk.
Does a kink prevent decompression?
Believing that it will continue to work and allow air to escape, it typically kinks and clogs and doesn't prevent the need for subsequent decompressions. If providers make this assumption they could potentially miss the return of symptoms.
When to use needle decompression?
A needle decompression should only be performed if the patient has a tension pneumothorax. When inserting the needle, it should be inserted at a 90-degree angle to the chest wall. This is a critical point as this will position the needle straight into the pleural space. If any other angle is used, there may be a chance of hitting other structures in the area such as major blood vessels or even the heart.
How long does a 14 gauge needle last?
Studies have determined that chest decompression with a 14 gauge needle is as successful as a chest tube in relieving a tension pneumothorax and therapeutic benefits can continue for as long a four hours. If using a needle catheter with a flash chamber, you should ensure that the chamber is removed.
What happens when a patient cannot compensate for a pneumothorax?
A tension pneumothorax occurs when the patient cannot compensate, and several events begin to occur that can lead to death. As air fills the pleural space on inspiration through the opening with an open pneumothorax, the wound can act as a one-way valve and not allow the air to exit.
What to do if tension pneumothorax is not improving?
If there is no improvement, the procedure will need to be repeated with another needle placed adjacent to the first needle. Monitor, then reassess the patient. A tension pneumothorax is a life-threatening situation.
How to treat an open pneumothorax?
For an open pneumothorax, treatment requires sealing the open wound with an occlusive dressing. This is often taught by using Vaseline gauze and securing the gauze to the patient's chest with tape. However, this can be a difficult process in the field depending on the size of the wound, the patient's condition, and the area the dressing is applied.
What happens when the vena cava is compressed?
This leads to difficulty breathing and tachycardia. A noticeable shift in the trachea will be evident. This entire process leads to a life-threatening condition known as a "tension pneumothorax." The patient in this condition will die if treatment is not provided.
Do needle catheters have flash chambers?
If using a needle catheter with a flash chamber, you should ensure that the chamber is removed. There are specially manufactured needles designed just for a tension pneumothorax. These are prepackaged 3.25-inch 14 gauge needles that do not have flash chambers.