# Needle Thoracostomy

## Overview

This module describes how to decompress a tension pneumothorax emergently and stabilise the patient until an intercostal drain can be established. For sampling fluid from the pleural space, see Thoracentesis.

## Indications

1. Tension pneumothorax with haemodynamic compromise

## Contraindications

1. None

## Patient information and consent

This procedure is usually done as an emergency measure. However, it may be explained to family members or the patient afterwards.

### How do I explain this procedure?

“The patient had a punctured lung, and the air from the puncture built up, squeezing the lungs and heart and putting their life at risk. I deflated this air pocket by puncturing it with a needle to reduce the pressure immediately. This was an emergency procedure.”

## Preparation

###

### Documentation

1. Patient notes

### Equipment

1. Non-sterile gloves

2. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

3. Alcohol-based hand rub

4. Alcohol swab

5. Surgical tape

6. Large-bore IV cannula (14-16 G) with a 5 cm needle

## Site & Positioning

The patient should be positioned supine. The insertion site is the second intercostal space in the midclavicular line. Insert the cannula just

above

above

A neurovascular bundle runs on the inferior surface of each rib and directing the needle just superior to the underlying rib avoids damaging it.

the third rib.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene and don gloves.

2. Clean the site with an alcohol swab.

3. In the rare event that there is time for anaesthesia,

   inject
   inject

   Aspirate with the syringe before injecting lignocaine to avoid injection into a blood vessel.

   1% lignocaine into the skin, subcutaneous tissue, rib periosteum (of the rib below the insertion site), and the parietal pleura. Proper location is confirmed by return of air in the anesthetic syringe when entering the pleural space.

4. Puncture the site with the large-bore cannula at a 90° angle to the skin.

5. Advance until you hear a rush of air, or all the way to the hub.

6. Remove the needle, leaving the cannula in situ.

7. Tape the cannula to the chest wall

   until
   until

   If there is some delay with insertion of the drain, ensure that the patient remains comfortable, stable and that the cannula has not become kinked.

   an intercostal drain can be inserted. This should be inserted as soon as possible after needle decompression, preferably immediately.

8. Dispose of medical waste safely.

9. Record completion of the procedure in patient notes.

## Troubleshooting

There is no rush of air.

In up to a third of patients, the chest wall may be too thick for the cannula to reach the pneumothorax. Proceed with an emergency intercostal drain.

After removal of the needle, the cannula has become kinked.

Insert a new cannula of the same size next to the first. Insert the intercostal drain as soon as possible.

There is a delay in placing a definitive drain.

Keep the patient under constant observation as the cannula may become obstructed while awaiting tube placement, or air in the pleura may accumulate faster than it can be expelled via the cannula. Multiple large-bore cannulas may be inserted but an intercostal drain is urgently needed.

## Risks

1. Minor bleeding and pain

2. Surgical emphysema

3. Reexpansion pulmonary oedema

4. Local infection or pleural infection

5. Recurrent pneumothorax

6. Sharps injury to healthcare personnel

## References

1. 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(1):111-114. doi:10.1097/01.ta.0000239241.59283.03