The United States military trauma researchers have found that tension pneumothorax (TP) is the second leading cause of preventable death in combat after hemorrhage from isolated limb loss. Needle thoracentesis or needle thoracostomy (NT) for decompression of TP is a life-saving procedure that must be correctly performed based on clinically sound techniques and guidelines. Incorrect technique for NT is associated with failure of relief of the life-threatening TP. The recommended technique and current guidelines for NT as described in the American Association for the Surgery of Trauma-Advanced Trauma Life Support (ATLS) entail inserting a 14-gauge, 5-cm long angiocatheter in the second intercostal space, in the midclavicular line of the affected side of the chest, as shown in the ATLS the video. NT inserted in the currently recommended technique has a high risk of transfixing the pectoralis major and minor muscles and may cause cardiac or pulmonary artery injuries, and this definitely can worsen an already existing hemodynamically unstable patient, leading to collapse and death. However, we have found that this technique is incorrect in all its aspects. First, the length of the needle is definitely too short to reach the pleural space in the majority of patients, particularly those with subcutaneous emphysema as shown in the presented video. Second, the insertion site is not safe particularly when it is not located in the safe triangle of the chest as previously shown to breach the pleural space safely and effectively. This has been supported by a cadaver-based study where NT was 100% successful when performed in the safe triangle of the chest compared with the traditional second intercostal space, in the mid-clavicular line with only 58% success. More support has been found by studies used computed tomography scans shown that the area of minimal chest wall thickness is to be the safe triangle of the chest, with higher success rates and fewer complications, when compared with the second intercostal space in the mid-clavicular line for NT.
Based on science and experience, the author recommends, therefore, a 14–16-gauge of a 15-cm long angiocatheter to be placed in the safe triangle of the affected side of the chest to buy time while approaching the hospital or in the resuscitation bay until a chest tube will be inserted safely as previously described.
Much appreciation goes to the patient for giving her consent for publication and education. The author acknowledges the assistance of Dr. Mohammad Abdelhay Mahdi Rashid, MD for compromising the video and the Ambulance personnel at Gravdal Hospital, Lofoten Islands, Norway, for recording the video, and for caring of the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has his consent for his images and other clinical information to be reported in the journal. The patient understand that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Laan DV, Vu TD, Thiels CA, Pandian TK, Schiller HJ, Murad MH, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury 2016;47:797-804.