# needle thoracostomy



## zzyzx (Mar 11, 2009)

From something I read recently, in 50% of patients (those having a broad chest) the 4.4 cm needle used by most EMS services for need decompression is not long enough to penetrate the pleural membrane. I don't understand this, so maybe someone can explain. Aren't you trying to place the needle into the space that has been created between the visceral pleura and parietal pleura? So wouldn't you hit that space as soon as you penetrated the chest wall past the parietal membrane?


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## AJ Hidell (Mar 11, 2009)

Once you do it, you'll be surprised just how deep you have to go to get there.  I was.  You figure that most caths are an inch and a half to two inches max.  It will take you over an inch just to get past the ribs.  And just like an IV, you want to be well past the point that it takes to merely penetrate.  You have to get it seated in there.  So yes, if you're not carrying anything that's two inches at the very least, you may encounter problems in many patients.  We're not all as slim as you!


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## zzyzx (Mar 11, 2009)

"We're not all as slim as you!" 

The article says that most EMS systems use 4.4 cm needles, but that can't be right. I'm not at work now and I don't remember how long our 10 gauge needles are, but they are pretty darn long. I just can't imagine them not being able to penetrate the chest wall, even on a muscular person.


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## Ridryder911 (Mar 11, 2009)

zzyzx said:


> "We're not all as slim as you!"
> 
> The article says that most EMS systems use 4.4 cm needles, but that can't be right. I'm not at work now and I don't remember how long our 10 gauge needles are, but they are pretty darn long. I just can't imagine them not being able to penetrate the chest wall, even on a muscular person.



10g ? That I would have to see. 

R/r 911


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## medic417 (Mar 11, 2009)

We use 14's here.


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## AJ Hidell (Mar 11, 2009)

10 gauge is certainly preferred, as it is much more efficacious, as well as less susceptible to clotting issues.  They are difficult to find though, and much sought after, even in Iraq.

As for the length, 4.4cm is only an inch and three-quarters.  That's about normal for a 14 gauge (with the standard range being posted above), and considered short for a 10 gauge.  So really, the length you are quoting is not a particularly mind-blowing thing.


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## zzyzx (Mar 11, 2009)

We have 10-gauge catheters in our kit. Elsewhere where I've worked, we used 12's. I don't know why this article was saying that most EMS providers use 4.4 cm needles, which, as you say, is about the standard length for a 14 gauge.


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## AJ Hidell (Mar 11, 2009)

Ah, I misread the post, and they are right.  Most 14 gaugers I have seen in recent years were 2 inches, if not two and a quarter inches long though.  That should certainly be sufficient.  The inch and a half to inch and three quarters (4.4cm) are pushing it though.  I have done needle decompressions that were certainly deeper than that.

How long are your 10 gauges?  The Army 10 gaugers were 3 inches.  We used them more for cutdowns than chest decompression though, opting most often for a chest tube.


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## Ridryder911 (Mar 11, 2009)

Usually, if you are in a service that carries 10g, then one should be advanced enough to carry a commercialized decompression kit that ensures proper length and decompression device. 

R/r 911


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## zzyzx (Mar 12, 2009)

Maybe I'm just being stupid about the gauge needle we carry. I'm not at work, but I'll check when I go back.


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## boingo (Mar 12, 2009)

Our 10g angio's are 3" long.


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## MSDeltaFlt (Mar 12, 2009)

We use 3" cath's on my ground service, but on my aircraft we have commercial kits.  We also have 10g's for pediatric needle crics.  Some will have one in their flight suit for multiple decompressions just in case.  If memory serves, they are at least 3", maybe 4", plenty long enough.

But, yeah, you're right. 4.4cm is awful short for a "dart".


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## medic417 (Mar 12, 2009)

Ours are 14g 3.25"  like these:

http://www.medplususa.com/list-prod...theter_14_G_x_3_25_50_per_Case-pid-29840.html


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## zzyzx (Mar 12, 2009)

Here is the abstract that I read (I was not able to access the full article):

Abstract 
Objective. Tension pneumothorax can lead to cardiovascular collapse and death. In the prehospital setting, needle thoracostomy for emergent decompression may be lifesaving. Taught throughout the United States to emergency medical technicians (EMTs) and physicians, the true efficacy of this procedure is unknown. Some question the utility of this procedure in the prehospital setting, doubting that the needle actually enters the pleural space. This study was designed to determine if needle decompression of a suspected tension pneumothorax would access the pleural cavity as predicted by chest computed tomography (CT). Methods. We retrospectively reviewed consecutive adult trauma patients admitted to a level I trauma center between January and March 2005. We measured chest wall depth at the second intercostal space, midclavicular line on CT scans. Data on chest wall thickness were compared with the standard 4.4-cm angiocatheter used for needle decompression. Results. Data from 110 patients were analyzed. The mean age of the patients was 43.5 years. The mean chest wall depth on the right was 4.5 cm (± 1.5 cm) and on the left was 4.1 cm (± 1.4 cm). Fifty-five of 110 patients had at least one side of the chest wall measuring greater than 4.4 cm. Conclusions. The standard 4.4-cm angiocatheter is likely to be unsuccessful in 50% (95% confidence interval = 40.7-59.3%) of trauma patients on the basis of body habitus. In light of its low predicted success, the standard method for treatment of tension pneumothorax by prehospital personnel deserves further consideration.


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## zzyzx (Mar 12, 2009)

What are the drawbacks of using a 10 gauge needle for tension pneumo decompression as opposed to a 12 or 14?


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## triemal04 (Mar 12, 2009)

Not a huge amount if done correctly.  The biggest issue you'd face with using a 10 or 12 gauge vs a 14 is the length; with some people it may be possible to puncture/lacerate the lung.  

That's ignoring the potential problems you always have: bleeding from a lacerated vein or artery if placed wrong which could potentially (technically) lead to a hemothorax, infection, an opening into the chest cavity, and as said, lacerating the lung itself.  Fun.

http://emedicine.medscape.com/article/432979-overview
More of how to recognize/treat a tension pneumo, but it does briefly talk about some complications.


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## medic417 (Mar 12, 2009)

Lung is already punctured sp even if needle punctures it again does not add to problem, just does not solve it.


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## AJ Hidell (Mar 12, 2009)

zzyzx said:


> What are the drawbacks of using a 10 gauge needle for tension pneumo decompression as opposed to a 12 or 14?


The biggest drawback is the difficulty in pushing that sucker through the chest wall.  It takes a significant effort to push a 14 through, and often results in bending the needle.  A 10 is a real chore, but isn't likely to bend.  A 2 or 2½ incher isn't going to present a problem of overpenetration.


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## triemal04 (Mar 12, 2009)

medic417 said:


> Lung is already punctured sp even if needle punctures it again does not add to problem, just does not solve it.


Yep, because the extra bleeding, extra damage and lack of even temporary resolution to the problem doesn't matter even one bit.


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## medic417 (Mar 12, 2009)

triemal04 said:


> Yep, because the extra bleeding, extra damage and lack of even temporary resolution to the problem doesn't matter even one bit.



Again said it does not solve the issue.  Have you ever been able to play with a fresh lung?  You can stab it with an IV within seconds of withdrawal it seals itself.  No bleeding.  No damage compared to the damage of leaving the pneumo untreated.


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## triemal04 (Mar 12, 2009)

Right.  So you just did a procedure that didn't fix the initial problem, and in fact, created more.  That could probably be seen as a drawback to most people.  Does it mean don't use longer catheters?  Absolutely not.  Does it mean that you have something else to be aware of?  Yep.

While a small puncture may seal itself, you have still caused further damage, bleeding, increased the chance of infection et al.  And while a laceration is rare (puncture is as well) it will not seal itself as quick, and lead to more bleeding, etc etc.  Sounds like a drawback to me.


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## AJ Hidell (Mar 12, 2009)

If it were harmless, it would be a basic skill.


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## triemal04 (Mar 12, 2009)

AJ Hidell said:


> If it were harmless, it would be a basic skill.


:censored::censored::censored::censored:, I'm surprised it's not; intubation has 10 times the number of associated problems, and in some places it's a basic skill.  :wacko:

Everything we do has pluses AND minuses, and many things will cause more damage, or have the potential to.  Doesn't mean that we should stop doing them, just that we should be aware of it.


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## Ridryder911 (Mar 12, 2009)

The problem I have had is simple angiocaths occlude. Yeah, I have brought patients in that looked like a porcupine. 

With commercialized kits, most have a nice large enough lumen and as well silicone inside that prevents kinkage and occulussion. 

R/r 911


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## medic417 (Mar 12, 2009)

triemal04 said:


> Everything we do has pluses AND minuses, and many things will cause more damage, or have the potential to.  Doesn't mean that we should stop doing them, just that we should be aware of it.



Very good point.  Sadly many ignore the possible bad effects and so do not prepare for the possibilty.  Nor will they do what is needed to limit the possibility of the bad effect.


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## Ridryder911 (Mar 12, 2009)

triemal04 said:


> :censored::censored::censored::censored:, I'm surprised it's not; intubation has 10 times the number of associated problems, and in some places it's a basic skill.  :wacko:
> 
> Everything we do has pluses AND minuses, and many things will cause more damage, or have the potential to.  Doesn't mean that we should stop doing them, just that we should be aware of it.




The problem is lung sounds are not technically a basic skill. So, recognizing a down lung is obvious a problem. In my state even an advanced or Intermediate are not allowed to decompress. 

R/r 911


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## zzyzx (Mar 12, 2009)

So if you guys could choose between using a 10, 12, and 14 gauge needle to decompress, which would you use?


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## medic417 (Mar 12, 2009)

http://www.narescue.com/Needle-Decompression-Kit-P18C2.aspx


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## triemal04 (Mar 12, 2009)

Ridryder911 said:


> The problem is lung sounds are not technically a basic skill. So, recognizing a down lung is obvious a problem. In my state even an advanced or Intermediate are not allowed to decompress.
> 
> R/r 911


As well they shouldn't, believe me, I'm not argueing for that.  But...just to get people yelling...for the states that allow basics to intubate...guess they should allow decompression; after all the basic must be proficient enough at lung sounds to be able to determine if the tube has slipped into the right/left bronchi...

Edit:  At least 12.  They are longer which leads to better success rates, and the incidences of further damaging the lung are pretty rare.  Plus the lumen is larger which keeps it from clotting over for longer and allows more air out rapidly...though that's a little relative.


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## TransportJockey (Mar 12, 2009)

I've only ever seen 14g used to decompression, but we've used the 3" caths in class. I start internship in 3 weeks and can report back then, but even the IFT company I worked for only had 14s as teh biggest we carried. I've never seen 12 or 10


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## Tal (Mar 13, 2009)

medic417 said:


> We use 14's here.



Same here. 
funny thing is, we sometimes use the infants chest drian vygon needle as a NA, but puncture the skin with scalple before penetrating.


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## maxwell (Mar 16, 2009)

I've never had a problem.  I have plenty of pts c ptx's and I use a #14 angio and get the fabulous (the real meaning of the words, root: fable) "woooosh" while the patients SaO2 comes up (FTW!).  I've heard this argument before - and I don't have much data that supports it.  Size (of the needle folks, come on, stay with me) here doesn't matter as long as its a standard angio.  Pediatrics...way different.  For neonates, I've seen butterflies used with good results.  For kids, #20s work okay.  

Remember, the worst thing about popping the chest with a needle is that you could hit lung (provided you dont go inferior to the superior rib and hit the VAN bundle...:deadhorse.  And hell, they're getting a chest tube anyway.


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## boingo (Mar 16, 2009)

Ummm...No, the worst thing that could happen is you could use an inappropriate sized catheter that never enters the pleural space, thus not decompressing the tension and the pt goes on to die.  Size DOES matter.  Don't kid yourself.  A 2" catheter is inadequate for most adult males with moderate muscle development, incidently the same demographic of pts I tend to see with these injuries.


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## maxwell (Mar 16, 2009)

boingo said:


> Ummm...No, the worst thing that could happen is you could use an inappropriate sized catheter that never enters the pleural space, thus not decompressing the tension and the pt goes on to die.  Size DOES matter.  Don't kid yourself.  A 2" catheter is inadequate for most adult males with moderate muscle development, incidently the same demographic of pts I tend to see with these injuries.



When I said "the worst thing" I meant the worst complication.  This is assuming you know what you're doing i.e. you know when you've decompressed it.  Moderate muscle development?  What?  You don't have fat gangsters?!  Let us not forget the tall, lanky, skinny dudes with spontaneous ptxs (had one yesterday!).  I used a 1.25" angio and worked just fine!


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## boingo (Mar 17, 2009)

http://www.anesthesia-analgesia.org/cgi/content/full/105/5/1385

Fat gangsters need even a longer catheter. Insert a large-bore (ie, 14-gauge or 16-gauge) needle with a catheter into the second intercostal space, just superior to the third rib at the midclavicular line, 1-2 cm from the sternal edge (ie, to avoid injury to the internal thoracic artery). Use a 3-6 cm long needle, and hold it perpendicular to the chest wall when inserting; however, note that some patients may have a chest wall thickness greater than 3 cm and failure for the symptoms to resolve may be attributed to inadequate

http://www.jtrauma.com/pt/re/jtraum...9f86bBh212QcL4h!-1046349743!181195628!8091!-1


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## Ridryder911 (Mar 17, 2009)

Also the lumen size should be emphasized. It has been well known most 14g cath occlude off. If a service performs these type of procedures often enough then they should invest in a commercialized kit.

R/r 911


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## rhan101277 (Mar 17, 2009)

boingo said:


> http://www.anesthesia-analgesia.org/cgi/content/full/105/5/1385
> 
> Fat gangsters need even a longer catheter. Insert a large-bore (ie, 14-gauge or 16-gauge) needle with a catheter into the second intercostal space, just superior to the third rib at the midclavicular line, 1-2 cm from the sternal edge (ie, to avoid injury to the internal thoracic artery). Use a 3-6 cm long needle, and hold it perpendicular to the chest wall when inserting; however, note that some patients may have a chest wall thickness greater than 3 cm and failure for the symptoms to resolve may be attributed to inadequate
> 
> http://www.jtrauma.com/pt/re/jtraum...9f86bBh212QcL4h!-1046349743!181195628!8091!-1




LOL fat gangsters


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## rhan101277 (Mar 17, 2009)

:deadhorse:


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## VentMedic (Mar 17, 2009)

rhan101277 said:


> :deadhorse:


 
You mean you did not learn anything from this thread?  The differences presented here makes this a worthwhile topic.  Granted EMT-Bs may not understand this now but some day you may want to advance.


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## reaper (Mar 17, 2009)

How can you say it is beating a dead horse, if you have never done it? This is a good argument.

Most services use a 14ga 3-3.5" long.  I would love for my service to go to 10's or 12's. 14's do clog off and then you have to put another one in.


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## bonedog (Mar 20, 2009)

The Turkel Safety needle works for most patients.( don't leave home with out it)
 If any amount of subcutaneous emphysema has accumulated the regular catheter's are useless. 
To say nothing of the mildly to morbidly obese.


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## DrankTheKoolaid (May 7, 2009)

*re*

sorry to bring up the dead on this one.  Just got a chance to perform this on a trauma patient the other day.  We only carry 1 each of the Thoracostomy and crich kits,   I ended up using both a 14ga and a 12ga midax and midclavic.  Guy ended up with a hemo-pneumo worsened by a ruptured diaphragm which would negate my decompressions minutes after performing em.

  Anyways the poor :censored::censored::censored::censored::censored::censored::censored: took em like a champ and prolly would have taken a 10ga without complaint also


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