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Proper Placement Is Needed for NDs

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Review of: Netto FA, Shulman H, Rizoli SB: "Are needle decompressions for tension pneumothoraces being performed appropriately for appropriate indications?" American Journal of Emergency Medicine. 26(5):597-602, 2008.

The Science

This Toronto, Canada study followed all patients who received needle decompression (ND) for suspected tension pneumothorax over a one-year period. The researchers noted the site of insertion, specifically measuring how close the site was to the midclavicular line. They examined all chest X-rays and CT scans as well as whether the patients received tube thoracostomies. They then reviewed the prehospital run report and rated the procedure as "indicated," "potentially indicated" or "not indicated." The criteria for performing ND was blunt or penetrating chest trauma, diminished or absent breath sounds, severe or worsening respiratory distress, and systolic blood pressure less than 90.

Seventeen patients received 18 needle decompressions. Overall, these 17 were younger patients who had more penetrating trauma, more severe injuries and a higher mortality rate than those who didn't receive ND. Seventeen of 18 NDs were performed in what has been described as the "Cardiac Box" -- an area known to have the potential for cardiac injury from ND. Eight were performed medial to the midclavicular line, and two didn't adequately decompress the pneumothorax due to the catheter being too small.

The researchers determined all cases to be either "indicated" or "potentially indicated."

The Street

Relief of a tension pneumothorax is a life-saving procedure, and other studies indicate the frequency of its use is on the rise. However, this paper raises some very concerning issues. The first is proper site selection for ND. The authors speculate that the tendency to inappropriately place the needle medial to the midclavicular line may be secondary to poor exposure of the trauma patient and not recognizing that the clavicle extends laterally to the shoulder.

There would be little to gain if a major vessel or the heart was injured. The authors didn't encounter a catastrophic cardiovascular complication. This may be due to this study's low numbers or it may only be a matter of luck. The authors suggest using the nipple as the landmark to improve the likelihood of missing the "Cardiac Box". This would become even more important if larger needles are utilized to ensure the pneumothorax is completely decompressed.

I challenge all large services to attempt to duplicate this study and follow up on these rare sentinel events. The more we learn about this procedure, the sooner we'll be able to adjust our education programs.

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