needle thoracostomy

[zzyzx]

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?

 

[AJ Hidell]

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!

 

[zzyzx]

"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.

 

[Ridryder911]

"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

 

[medic417]

We use 14's here.

 

[AJ Hidell]

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.

 

[zzyzx]

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.

 

[AJ Hidell]

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.

 

[Ridryder911]

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

 

[zzyzx]

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.

 

[boingo]

Our 10g angio's are 3" long.

 

[MSDeltaFlt]

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".

 

[medic417]

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

 

[zzyzx]

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.

 

[zzyzx]

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

 

[triemal04]

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.

 

[medic417]

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

 

[AJ Hidell]

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.

 

[triemal04]

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.

 

[medic417]

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.