Needle thoracostomy is an emergency, potentially life-saving, procedure that can be done if tube thoracostomy cannot be done quickly enough.
Indications
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Tension pneumothorax that must be decompressed before tube thoracostomy can be done
Contraindications
Complications
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Pulmonary or diaphragmatic laceration
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Intercostal neuralgia due to injury of the neurovascular bundle below a rib
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Bleeding
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Infection
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Pneumothorax (if the procedure was done because of falsely suspected pneumothorax)
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Rarely, perforation of other structures in the chest or abdomen
Equipment
Additional Considerations
Positioning
Relevant Anatomy
Step-by-Step Description of Procedure
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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.
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If time permits, prepare the area at and around the insertion site using an antiseptic solution such as chlorhexidine.
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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.
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Insert the thoracostomy needle, piercing the skin over the rib below the target interspace, then directing the needle cephalad over the rib until the pleura is punctured (usually indicated by a pop and/or sudden decrease in resistance).
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After doing a needle thoracostomy, insert a chest tube as soon as possible.
Aftercare
Warnings and Common Errors
Tips and Tricks
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After removing the needle, the catheter may become blocked by kinking. Kinking is especially likely with smaller catheters, such as 14 and 16 gauges. Some sources recommend using a larger 10-gauge needle and catheter (1, 2, 3).
References
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1. Aho JM, Thiels CA, El Khatib MM, et al: Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. J Trauma Acute Care Surg 80(2):272–277, 2016. doi: 10.1097/TA.0000000000000889
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2. Clemency BM, Tanski CT, Rosenberg M, et al: Sufficient catheter length for pneumothorax needle decompression: A meta-analysis. Prehosp Disaster Med 30(3):249–253, 2015. doi: 10.1017/S1049023X15004653
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3. Beckett A, Savage E, Pannell D, et al: Needle decompression for tension pneumothorax in Tactical Combat Casualty Care: Do catheters placed in the midaxillary line kink more often than those in the midclavicular line? J Trauma 2011 71(5 Suppl 1):S408–412, 2011. doi: 10.1097/TA.0b013e318232e558
Drugs Mentioned In This Article
| Drug Name | Select Trade |
|---|---|
lidocaine |
XYLOCAINE |
