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Needle Thoracostomy (Emergency Medicine)

PRE-PROCEDURE
INDICATIONS
  • Suspected or confirmed tension pneumothorax with signs of clinical deterioration.
CONTRAINDICATIONS
  • There are no absolute contraindications to needle thoracostomy.
  • No data exist on the safety of the procedure in patients with a coagulopathy; if it must be performed in these situations, meticulous attention must be paid to anatomy and technique.
EQUIPMENT
  • Skin-cleansing agent (chlorhexidine or povidone-iodine)
  • 14- to 16-gauge, 5-cm, over-the-needle catheter (catheters without safety devices are ideal)
  • 10-mL syringe (optional)
ANATOMY
  • Second intercostal, midclavicular approach (generally preferred)
    • The second rib articulates with the sternomanubrial joint. The second intercostal space lies below the second rib.
  • Fourth or fifth intercostal, midaxillary approach
    • The midaxillary portion of the fifth rib is generally at nipple level in most adults. The fourth and fifth intercostal spaces lay below the fifth and sixth ribs, respectively.
Tension pneumothorax on chest radiography
Figure 2 :  Tension pneumothorax on chest radiography

Equipment
Figure 3 :  Equipment

Mid-clavicular insertion site
Figure 6 :  Mid-clavicular insertion site


PROCEDURE
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Perpendicular needle entry in mid-clavicular approach
Figure 12 :  Perpendicular needle entry in mid-clavicular approach

Perpendicular needle entry in mid-axillary approach
Figure 13 :  Perpendicular needle entry in mid-axillary approach


POST-PROCEDURE
CARE
  • Chest tube insertion is mandatory after needle thoracostomy.
  • Obtain a portable chest radiograph.
COMPLICATIONS
  • Failure to decompress the tension pneumothorax (try again with a longer catheter, or insert a chest tube)
  • Bleeding
  • Iatrogenic pneumothorax
  • Infection
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