Needle Thoracostomy: Where To Put It?

This is another one of those “everything you know is wrong” posts. Since forever, we’ve been taught that an emergent needle thoracostomy should be placed in the second intercostal space, mid-clavicular line. But how do we know?

Once again, the crew at USC+LAC has taken a new look at something we take for granted. They studied thoracostomy insertion in 20 cadavers, using both the classic insertion site as well as a fifth intercostal space, mid-axillary line position.

They found that only 58% of classically placed needles entered the chest cavity, while 100% of the 5th intercostal space catheters were successful. The success rate in the classic position in males was 75%, but in females was only 17%. The authors speculate that the perfect success rate with the lateral approach was due to the absence of extra tissue over the second intercostal space (pectoralis muscle, breast tissue).

Bottom line: Always question dogma. Granted, there are some limitations with this study (using dead people, age and weight not available). Nevertheless, this correlates with my experience, especially when shorter (5cm long) catheters are used. Although I will not necessarily change my practice immediately until there’s a little more literature, I will keep this in mind for obese patients or in those where traditional placement doesn’t seem to be having the desired effect.

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Reference: Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma 71(5):1099-1103, 2011.

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