Thread by @alexandrucarap

Hi @Me4Trauma and #SoME4Trauma people. Let's get started with our first tweetorial covering needle decompression of the chest for tension pneumothorax.
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9th ed of ATLS recommended using a 5cm long cath in the 2nd IC space on the midclavicular line. The 10th ed recommends using an 8 cm cath in the 4th or 5th IC space anterior to the midaxillary line. What led to these changes?
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Several papers looked at chest wall thickness(CWT) and found that the 2nd IC space led to high failure rates. Comparing CWT at the 2nd IC space MCL and 4/5th IC space AAL found decreased CWT at the 4/5th space meaning lower failure rates. Let's look at some of them
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Harcke et al measured CWT at 2nd IC MCL with CT scans in 101 male from the military
- mean CWT: 5.36cm, 4.86cm
- CWT increased with age
- success of decompression w/ 5cm cath - 50%, w/ 8cm cath 99%
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ncbi.nlm.nih.gov/pubmed/18274025

Inaba et al compared CT CWT measurements between 2nd IC and 5th IC
- civilian population
- smaller CWT overall for 5th IC AAL and across BMIs
- failure rate of 5cm cath: 42.5% 2nd IC, 16.7% 5th IC
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ncbi.nlm.nih.gov/pubmed/22987168

Chang et al used CT to determine if an 8cm cath would work and avoid iatrogenic injury (Distance to Vital Structure DVS) at 4th ICS AAL
- smaller CWT at 4th IC compared to 2nd IC
- CWT and DVS increase with BMI
(cont)
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ncbi.nlm.nih.gov/pubmed/24662868

Chang et al used CT to determine if an 8cm cath would work and avoid iatrogenic injury (DVS) at 4th ICS AAL
- successful decompression w/ 8cm cath - 96% across all sites, 5cm cath - 66-81%
RD - radiologic decompression
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ncbi.nlm.nih.gov/pubmed/24662868 6

Sanchez et al found the exact opposites 😊; CT measurement of CWT comparing 2nd IC with 4/5th IC
- CWT lower in 2nd IC
- failure rate lower in 2nd IC
- women had shorter CWT
(CT scan of measurements might explain these strange results)
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ncbi.nlm.nih.gov/pubmed/21951681

A systematic review and meta-analysis by Laan et al of CT measurements of CWT found:
- shorter CWT at 4/5th IC compared to 2nd IC
- higher failure rates for 2nd IC when compared to 4/5th IC for 5 cm cath
- highlight geographic distribution
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ncbi.nlm.nih.gov/pubmed/26724173

An earlier trial by Ball et al looked at decompression failure comparing 3.2cm (ground) with 4.5cm (helicopter) cath in the 2nd IC space MCL. Failure - PTX on ultrasound or occult PTX on CT
- failure: 65% w/ 3.2cm cath vs 4% w/4.5cm cath
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ncbi.nlm.nih.gov/pubmed/20507791

Several papers compared failure rates, ease of placement and device stability for the 2nd IC and the 4/5th IC on cadavers. Let's look at three of them.
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Inaba et al compared failure rates for decompression in the 2nd IC MCL and 5th IC MAL with a 5 cm cath
- CWT 3.5 cm 5th IC vs 4.5 2nd IC
- success: 100% 5th IC vs 57.5% 2nd IC
- higher failure rate in females
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ncbi.nlm.nih.gov/pubmed/22071914

Inaba et al compared the 2nd IC MCL vs 5th IC MAL for prehospital providers (8 cm cath)
- the 5th IC was rated as easier than the 2nd
- higher accuracy for the 5th IC
- greater overall aggregate distance from correct site for the 2nd IC
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ncbi.nlm.nih.gov/pubmed/26488319

Leatherman et al looked at device stability during movement (cadavers, 4 devices: 10G and 14G 8 cm cath, modified Veress needle and a 3 mm laparoscopic trocar) (2nd vs 5th AAl)
- higher rate of dislodgement and higher displacement for 2nd IC
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ncbi.nlm.nih.gov/pubmed/28383466

Let's now look at two papers that used animal models to test the efficacy of needle decompression. As highlighted in one of the papers, animal models might be the best we can get when researching tension pneumothorax.
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Martin et al compared the efficacy of a 14G 8cm cath vs chest tube in a porcine model for 2 scenarios: tension physiology and pulseless electrical activity
Success rate
- tension: chest tube 100% v cath 42%
- PEA: chest tube 100% v cath 36%
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ncbi.nlm.nih.gov/pubmed/22902737

Leatherman et al compared 4 devices (10 and 14G 8 cm cath, modified Veress, 3 mm trocar) in the 2 scenarios above
Success rate
- tension: 10G - 90%, trocar - 98%, Veress - 82%, 14G - 74%
- PEA: 10G, trocar - 100%, Veress - 57%, 14G - 50%
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ncbi.nlm.nih.gov/pubmed/28885469

To end in a cautious note, Wernick et al do a great job of reviewing complications of needle decompression.
And, if you're in the correct setting and properly trained, finger thoracostomy works 100% of the time and takes seconds.
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ncbi.nlm.nih.gov/pubmed/26557486

Hope you enjoyed. Give me or @Me4Trauma feedback on the format. And please join the discussion if you disagree or feel something has been left out.
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