Advertisement

Using Ultrasound to Determine Optimal Location for Needle Decompression of Tension Pneumothorax: A Pilot Study

      Abstract

      Background

      Chest injury can result in life-threatening complications like tension pneumothorax, in which rapid deterioration can occur without decompression. Traditionally, the second intercostal space (ICS) along the mid-clavicular line is taught as the site for decompression. However, this has been questioned due to high rates of treatment failure. The fifth ICS on the mid-axillary line (MAL) is hypothesized to have a shorter distance from skin to pleura based on recent studies.

      Objective

      The purpose of this study was to use point-of-care ultrasound (POCUS) to compare chest wall thickness at these two locations. The primary objective was to evaluate the distance from skin to pleura line at the second ICS along the mid-clavicular line and the fifth ICS along the MAL. Secondarily, we aimed to evaluate inter-rater reliability of the two assessments.

      Methods

      This was a single-center, observational, pilot study. POCUS was performed using a linear transducer. Measurements of skin to pleura line were obtained at the right second ICS and fifth ICS. These measurements were then repeated by a blinded second ultrasonographer. Intraclass correlations (ICCs) for each measurement site were calculated to determine the inter-rater reliability.

      Results

      Ninety-three percent of volunteers had a smaller chest wall distance at the fifth ICS-MAL. The median distance at the second and fifth ICS was 2.28 cm and 1.80 cm. The ICC for second ICS was 0.75 (95% CI 0.54–0.87), and 0.90 for the fifth ICS (95% CI 0.81–0.95), both indicating good reliability.

      Conclusions

      The data support that patients have a smaller chest wall distance at the fifth ICS vs. the second ICS. We support performing needle decompression at the fifth ICS and believe POCUS can be used to determine the optimal location for decompression.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Zengerink I
        • Brink PR
        • Laupland KB
        • Raber EL
        • Zygun D
        • Kortbeek JB.
        Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle?.
        J Trauma. 2008; 64: 111-114
        • Stevens RL
        • Rochester AA
        • Busko J
        • et al.
        Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography.
        Prehosp Emerg Care. 2009; 13: 14-17
        • Koo TK
        • Li MY.
        A guideline of selecting and reporting intraclass correlation coefficients for reliability research [published correction appears in J Chiropr Med. 2017 Dec;16(4):346].
        J Chiropr Med. 2016; 15: 155-163
        • Inaba K
        • Ives C
        • McClure K
        • et al.
        Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax.
        Arch Surg. 2012; 147: 813-818
        • Inaba K
        • Branco BC
        • Eckstein M
        • et al.
        Optimal positioning for emergent needle thoracostomy: a cadaver-based study.
        J Trauma. 2011; 71 (discussion 1103): 1099-1103