NEEDLE THORACOSTOMY
(PLEURAL DECOMPRESSION)

INDICATIONS:

• Patient with Suspected Tension Pneumothorax:

• Decreased/Absent Breath Sounds on the Affected Side, Dyspnea, Hypoxia, Poor Chest Wall Excursion, Hyperresonance to Percussion on the Affected Side, and Pallor/Cyanosis, PLUS
• Hypotension
• Shock
• Increased airway resistance to assisted ventilation (“hard to bag”)
• Jugular Venous Distention (JVD) – may be absent if the patient is hypovolemic
• Tracheal Deviation – late sign, detected only by palpation in suprasternal notch

COMMON SETTINGS:

• Trauma
• Cardiac Arrest & Severe Dysrhythmias (e.g. PEA, Bradycardia with Poor Perfusion)
• Asthma, COPD
• Any patient on positive pressure ventilation (BVM or advanced airway)

DIFFERENTIAL DIAGNOSIS:

• Massive Hemothorax (dullness to percussion, no JVD)
• Cardiac Tamponade (symmetrical breath sounds, symmetrical chest excursion, muffled heart tones)
• Right Mainstem Intubation (no hypotension/shock, no hyperresonance, no JVD)
• Simple Pneumothorax (no hypotension/shock, usually no cyanosis, no tracheal deviation)

PROCEDURE (Observe Body Substance Isolation Precautions):

1. Equipment needed:

• Large, long, non-needle-guard IV catheter (Adult: 14 g  or 16 g., at least 2½” long; Pediatric: 18 g.)
• Iodine skin cleanser

2. Locate anatomic landmarks:  2nd intercostal space at the mid-clavicular line on the affected side

• Prepare the area with betadine
• Palpate the clavicle, then 2nd rib, then 3rd rib (1st rib is not palpable under the clavicle)
• Insertion site: mid-clavicular line, over the top of the 3rd rib (2nd intercostal space)
• Alternate site: mid-axillary line, 4th intercostal space (no lower than the nipple line), over the top of the 5th rib, in the relatively thin area between the pectoralis and the latissismus dorsi muscles

3. Remove the cotton plug from the IV catheter (if present) and insert the catheter over the top of the 3rd rib, perpendicular to the chest wall (do not angle the tip of the catheter towards the patient’s head):

• When the catheter enters the pleural cavity, there will be a palpable “pop” and a rush of air through the needle:
• Conscious patients may report immediate resolution of dyspnea, with improved vital signs
• Unconscious patients may become easier to ventilate, with improved vital signs
• Advance the catheter over the needle into the pleural space until the catheter hub is flush with the skin, withdrawing and removing the needle

4. Reassess and document the patient’s HR, BP, respiratory rate, cardiac rhythm, ETCO2, SpO2, bilateral breath sounds, JVD, level of consciousness, and chest wall excursion
5. Prepare for transport
6. Reassess and document the patient’s HR, BP, respiratory rate, cardiac rhythm, ETCO2, SpO2, bilateral breath sounds, JVD, level of consciousness, and chest wall excursion frequently en route:

• Catheter displacement, kinking or clotting can cause reoccurrence of the tension pneumothorax
• If this occurs, leave the catheter in place, and repeat the insertion procedure with a 2nd catheter in the same intercostal space, adjacent to the first one

COMPLICATIONS:

• Local hematoma, pneumothorax, lung or blood vessel laceration