1-11. Needle Thoracostomy

Suspect tension pneumothorax in the patient who has decreased breath sounds unilaterally or throughout the lungs and persistent hypoxia with poor lung compliance. Particularly, at risk are patients with severe blunt trauma or penetrating trauma to the chest or abdomen who are receiving positive pressure ventilation. Note that additional signs of tension pneumothorax such as tracheal deviation and subcutaneous emphysema may be absent.

1) Establish an IV access and provide high flow oxygen.

2) Consider diagnostic mimics like improper endotracheal tube placement (ETT too deep) and hemothorax. Also consider your ETA to the ED, and time to communicate a possible diagnosis and trauma activation alert to the ED.

3) If the oxygen saturation cannot be maintained above 90% and there is either BP ≤ 80 mmHg systolic (impending cardiac arrest) or PEA, then perform a needle thoracostomy to decompress the suspected tension pneumothorax.

4) Do this at the midclavicular line at the 2nd intercostal space or at the anterior axillary line 5th intercostal space.

5) Use a special long and large catheter: 14 ga X 3 ¼” length.

6) Insert the needle into the chest wall perpendicular to the rib. Once the needle contacts the rib, then direct the needle over the rib into the target interspace.

7) Leave the catheter in place.

8) Post procedure: recheck VS, lung sounds, POX, and then report any changes to the ED.