Here’s a quick, 3 ½ minute video for physicians and paramedics on how to decompress the chest when you suspect a tension pneumothorax.
If you’ve got a few tips or tricks that you’d like to share on this procedure, please comment on the YouTube video.
Kenji Inaba and colleagues have done a lot of work on tension pneumothorax (tPTX) in the past few years. They’ve looked for the best devices and the best positions on the chest to quickly and effectively treat this emergency. Now, they’ve published a study on using what looks like a “better mousetrap” for relieving tension physiology.
Previous work from this lab has shown that up to a quarter of needle thoracostomies fail within 5 minutes due to mechanical reasons. This leaves a small window for insertion of the real chest tube. And even though much of the pressure may be relieved, a significant amount of air may be left in the chest, impeding recovery from PEA arrest.
They looked at the use of a 5mm laparoscopy port for relief of tension pneumothorax in Yorkshire swine. The exact size of the pigs was not listed, but these animals weigh 25 pounds at 6 weeks of age, and the pictures in the article show a reasonable sized animal. I’m not sure they were 70kg, though.
Here are the factoids:
Bottom line: Once again, Inaba and crew have added some interesting tidbits to our knowledge base. You already know I’m not a fan of animal studies like this, but this one lays the ground work for some work in humans. We still need to know how the “usual American body habitus” will affect the use of this device. The only downside is the expense of the trocar, which is a lot more than a simple long needle. But if it is as efficacious in humans as it is in pigs, it may be worth it!
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Reference: Standard laparoscopic trocars for the treatment of tension pneumothorax: A superior alternative to needle decompression. J Trauma 77(1):170-175, 2014.
I’ve recently written about the merits of needle vs finger thoracostomy. One of the arguments against needle thoracostomy is that it may not reach into the chest cavity in obese patients. As I mentioned yesterday, use the right needle!
Obviously, the one on top isn’t going to get you very far. The bottom one (10 gauge 3 inch) should get into most pleural spaces.
But what if you don’t have the right needle? Or what if the patient is massively obese and the longer needle won’t even reach? Pushing harder may seem logical, but it doesn’t work. You might be able to get the needle to reach to the pleural space, but the catheter won’t stay in it.
Here’s the trick. First, make the angiocatheter longer by hooking it up to a small (5 or 10cc) syringe. Now prep the chest over your location of choice (2nd intercostal space, mid-clavicular line or 5th intercostal space, anterior axillary line) and make a skin incision slightly larger than the diameter of the syringe. Now place the syringe and attached needle into the chest via your incision. It is guaranteed to reach the pleura, because you can now get the hub of the catheter down to the level of the ribs. Just don’t forget to pull out the catheter once you’ve placed the chest tube!
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I continue to see interest in using finger thoracostomy in place of needling the chest for the management of real or presumed tension pneumothorax. As noted in the title, I don’t really care for this procedure. I know that there’s a lot of opinion on this topic out there, especially in blogs. My colleague, Scott Weingart (EMCrit) has a very nice podcast on the topic (link below). But the actual scientific literature supporting or condemning its use is sparse.
The procedure consists of doing a limited prep of the chest in the same location for regular chest tube placement, incision, rapid puncture of the parietal pleura, followed by placement of a finger into the pleural space to release tension. Sounds well and good! So what’s my beef? The arguments for it emphasize speed, certainty, and reversibility.
Let’s talk about speed first. This procedure is supposed to be fast. An incision, a few quick sweeps with a clamp, and voila! Finger inserted. And it can be this fast. But in reality, especially in training centers, people who don’t insert chest tubes very often take too long (1-2 minutes).
The next argument is certainty. There are a number of papers showing that needle thoracostomies often miss the mark, especially when using standard through the catheter needles. This is more likely to occur when the needle is inserted in the standard location (2nd intercostal space, midclavicular line) and in obese patients. My response is, use a longer needle!
The angio-catheter on top is a standard 14Ga 1.25 inch model, and won’t get you anywhere. It’s only good for thin people, and will kink as soon as the needle is withdrawn. The bottom model is 10Ga 3 inch, and is effective in everyone save the very morbidly obese. It’s thick and will not kink until it gets good and warm.
The final issue is reversibility. The argument goes, stick a needle in the lung and you’ll get a pneumothorax, but stick a finger in the chest and no harm done. I don’t completely buy this. Puncturing the lung does not a guarantee a pneumothorax. But it will require a subsequent chest xray to see if one develops. Finger thoracostomy doesn’t guarantee that a pneumothorax won’t occur. It also requires a chest xray later to check.
Bottom line: As you can tell, I’m not a big fan of finger thoracostomy, mainly due to speed (or lack thereof). Just stock some big fat needle catheters in your trauma bay and be done with it. But if you really, really want to use the finger technique, make sure that the person doing it is very experienced. This is not a learner’s procedure. It should take no more than 15 seconds, or the wrong person is doing it.
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This video demonstrates tips, indications and technique for performing needle decompression of the chest for tension pneumothorax.