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Procedural Skills (SLO6)
Question 28 of 141
A 21 year old is brought into ED with a stab wound. During the primary survey, your consultant diagnoses a tension pneumothorax and advises you to perform an immediate needle thoracocentesis. What is the recommended site for insertion?
Answer:
- According the the latest (10th edition) of the ATLS:
- For paediatric patients, the 2nd intercostal space midclavicular line is appropriate
- For adults (especially with thicker subcutaneous tissue), use the fourth or fifth intercostal space anterior to the midaxillary line
Needle Thoracocentesis
Procedural Skills (SLO6)
Last Updated: 14th March 2021
Indications
- Initial emergency treatment for patient with suspected tension pneumothorax
- N.B. Chest drain is the definitive treatment for tension pneumothorax
Contraindications
- Nil
Procedure
- Assess the patient's chest and respiratory status
- Administer high-flow oxygen and ventilate as necessary
- Surgically prepare the site chosen for insertion
- According the the latest (10th edition) of the ATLS:
- For paediatric patients, the 2nd intercostal space midclavicular line is appropriate
- For adults (especially with thicker subcutaneous tissue), use the fourth or fifth intercostal space anterior to the midaxillary line
- According the the latest (10th edition) of the ATLS:
- Insert an over-the-needle catheter 3 in. (5 cm for smaller adults; 8 cm for large adult) with a Luer-Lok 10 mL syringe attached into the skin; direct the needle just over the rib into the intercostal space, aspirating the syringe while advancing
- Puncture the pleura
- Remove the syringe and listen for the escape of air when the needle enters the pleural space to indicate relief of the tension pneumothorax.
- Advance the catheter into the pleural space
- Stabilise the catheter and prepare for chest tube insertion
Complications
- Failure of decompression
- Cannula too short to reach the pleural space
- Improper placement of cannula
- Blood clot obstructing cannula
- Kinking/compression of cannula
- Air leak rate greater than air evacuation by needle
- Missed localised pneumothorax
- Other major:
- Iatrogenic pneumothorax
- Haemothorax
- Haemorrhage
- Major vascular and cardiac injury
- Pneumonia and empyema
- Minor:
- Pain
- Cough
- Local haematoma
- Atelectasis
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
