Podcast 62 – Needle vs. Knife II: Needle Thoracostomy? - a podcast by Scott D. Weingart, MD FCCM

Needle vs. Knife Part II

In this podcast, I explain why I don't think needle compression is such a clever idea. Main points are: most people can't find anterior target, most angiocaths won't reach, and if used diagnostically you may not be in the pleura leading to an unidentified pneumo or hemothorax. Also, when used diagnostically, if the chest was negative you just caused a pneumothorax.



If you haven't already, you should listen to Needle vs. Knife Part I with Minh. Also, may of the issues discussed here are also mentioned in the finger thoracostomy episode and the traumatic arrest episode.

Why the standard approach to needle decompression sucks

Normal IV catheters do not reach in up to 65% of the cases

Can J Surg. 2010 Jun;53(3):184-8.



Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7



J Trauma. 2008 Jan;64(1):111-4



J Trauma 2008 Oct;65(4)":964



Accid Emerg Med 1996;6:426–7



Injury 1996;5:321–2.



Brand New Study state failure in 42% of cases (Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax Arch Surg. 2012 Sep 1;147(9):813-8)



 

Anterior Approach is not Where You Think it is

Emerg Med J 2003;20:383-384



ED Docs got it wrong a lot! (Emerg Med J 2005;22:788)





Use the Lateral Approach if you are going to do Needle Thoracostomy

ANZ J Surg. 2004 Jun;74(6):420-3

Study says Anterior is closer, but (smooth concept here) the patients had their arms in the air

(Acad Emerg Med 2011;18:1022)

Even if you get it right, Cannula may kink, occlude, or compress

Emerg Med J 2002;19:176-177

Traumatic Arrest is not Dismal until Tension Pneumo is Ruled Out

Emerg Med J. 2009 Oct;26(10):738-4

This device makes much more sense to me

Evaluation of ThoraQuik: a new device for the treatment of pneumothorax and pleural effusion (Emerg Med J 2011;28:750-753)



Michelle Lin did a great blog post about the stuff in this podcast on her Academic Life in EM Blog.

Update:

Hot off the press is this swine simulation demonstrating that even when a 14G catheter reached, it may not be sufficient to drain a tension pneumo (Journal of Trauma and Acute Care SurgeryIssue: Volume 73(6), December 2012, p 1410–1415)

A Video Demonstrating Finger Thoracostomy by Cliff Reid



Additional References

Deakin, C., Davies, G., & Wilson, A. (1995) Simple thoracostomy avoids chest drain insertion in prehospital trauma. The Journal of Trauma: Injury, Infection, and Critical Care. 39(2). 373-374.



Masarutti, D., Trillo, G., Berlot, G., Tomasini, A., Bacer, B., D’Orlando, L., Viviani, M., Rinaldi, A., Babuin, A., Burato, L., & Carchietti, E. (2006) Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews. European Journal of Emergency Medicine. 13. 276-280

Want a recorded lecture on the topic?

Michael McGonigal had me to his Trauma Conference for this lecture on the finger

Updates

See these observations from the military

Further episodes of EMCrit Podcast

Further podcasts by Scott D. Weingart, MD FCCM

Website of Scott D. Weingart, MD FCCM