REBEL Core Cast 33.0 – Needle Decompression

Posted by Marco Torres on May 13, 2020

Take Home Points

REBEL Core Cast 32.0 – Needle Decompression

Tension pneumothorax is a clinical diagnosis
Expect the pathology in a patient with chest injury, hypotension, unilateral breath sounds, tracheal deviation, hypotension and potentially hypoxia
Physical exam, however, is unreliable

2015 meta-analysis archives of surgery

<66% of patients had diminished breath sounds on the same side as lung collapse
10% of patients had diminished breath sounds on the opposite side of lung collapse
Classic findings, as usual, are actually uncommon
- Tracheal deviation and hypotension occurred in less than 1 in 5 patients
- Hypoxia occurred in less than 1 in 10 patients
- JVD occurred in less than 1 in 20 patients

Lung sliding is absent in collapsed lung
M mode findings
- Seashore appearance in normal lung – subcutaneous tissue resembles the sea and normal lung resembles the sand
- In pneumothorax has barcode appearance, due to absence of lung movement

Traditional Approach
- 2nd intercostal space in the midclavicular line
- Difficulty finding the correct anatomical site, often times going too medially
- 14g angiocath (with 5cm length) will fail to reach the chest cavity in more than 50% of cases
Modern Approach
- 4th or 5th intercostal space in the anterior axillary line
- Chest wall is thinner making it easier to reach chest cavity
- Less vital structures that could be injured
- Easier to identify correct anatomical landmarks

Often times decompression done in the field and with repeated moves needle catheter can become dislodged
Angiocath is also prone to kinking, plastic catheter becomes softer at body temperature and can kink when needle removed.
Journal of Trauma and Acute Care surgery 2012 showed needle decompression failed 20% of the time due to kinking and dislodgement

Recommend needle decompression with 10g, 8cm angiocath angled perpendicular to the skin
Hubbing catheter to the skin, and holding the entire needle/catheter unit in place for 5-10 seconds to improve decompression.

In crashing tension pneumothorax patient the most important thing is getting access to the chest cavity and guaranteeing decompression of tension pneumothorax
May have less cognitive load burden secondary to just having to use a knife and finger
Additionally in these cases will need to follow up with a chest tube so easy enough to finger decompress than follow it up with a chest tube