Needle Decompression

As he prepared his implement he gazed down at her chest attentively.

“Which is the right spot?” he wondered as nervous sweat beaded over his brow. He was angry with himself for fumbling. He had seen it so many times before on TV and on the internet. What would she think he wondered? What was she thinking? Finally he could wait no more. He drew his breath, beared down and…

BAM! He was in. He had done it. Not even that much blood. Her eyes shot open as she breathed in deeply..

Yes the needle thoracostomy provides… (dirty minds you).

The needle thoracostomy, colloquially known as a needle decompression, is an invasive therapeutic measure commonly indicated for the relief of an acute pneumothorax. It has been depicted on House, MD twice that I know of and was also detailed graphically during the movie Three Kings (the guy with the chest valve).

A pneumothorax can arise through various routes including: Secondary to trauma & medical conditions; An accumulation of blood within the pleural cavity (haemothorax); As well as primary causes including spontaneous aetiologies. Left untreated a pneumothorax can cause numerous critical threats to the patient including impedance of venous return to the heart (a common sign is jugular vein distention in the neck) and respiratory distress due to the changing pressure differential within the pleural cavity (ref: the Merck Manual)

My – short and unthorough – research indicates needle decompressions are within the scope of practice for ALS (Advanced Life Support) ambulances in most Canadian provinces. The Paramedic Association of Canada’s NOCP lists the intervention for the two upper tier training levels – ACP and CCP, for you Albertans EMT-P (ref: PAC NOCP, p.114)

Current clinical indications for a needle decompression are:

  • patient aged at least 12 years and weighing min. 40 kg
  • severe and worsening shortness of breath or respiratory distress
  • absent or markedly decreased breath sounds on the affected side
  • systolic blood pressure of 90 mm Hg or lower (ref: Netto et al, 2008)

Not a very healthy camper. If these criteria are met the medic is allowed to carry out the intervention without radioing to Medical Command for a Physician order. Supplemental oxygen is applied and the insertion site is cleansed. A spot is selected on the affected side (lack of breath sounds, side contralateral to tracheal deviation) on the mid-clavicular line of the 2nd intercostal space  (space between the 2nd and 3rd rib) on the Px anterior chest wall. A needle (usually 14 guage) and catheter are then inserted approximately 2″ into the pleural cavity aspirating for free air. The needle is then removed and the catheter secured into place.  (ref: Netto et al, 2008). I have not found much research indicating significant adverse affects. There was one paper published in the Journal of Emergency Medicine that suggested spontaneous pneumothoracies in geriatric patients could be treated without a NT (ref: Chan et al, 2009)

My question is whether this treatment is an intervention you personally would consider during an emergency in a remote setting?

Although I am generally hesitant to advocate rogue medical treatment I do consider a pneumothorax relatively probable during mountaineering excursions. After a few hours of climbing frozen pointy daggers with pointy axes one can not be blamed for considering such injuries. I also read a recent review of high-altitude illness published in the Lancet that mentioned an increased rate of spontaneous pneuomothoracies during quick high-altitude ascents (ref: Basnyat, 2003)

The US Military has made considerable advances in pneumothorax treatment research during the past decade. The video below details a product you can buy for $15 US. It is basically a modified catheter and needle placed inside a durable tube not much bigger than a pen. When considering a typical mountaineering trip’s 5km hike in and the overall lack of cell coverage a conscious partner (or me) has a far higher chance of surviving a pneumothorax if they are self-mobile. Another article published on US Military research found that a lack of a palpable radial pulse was a statistically significant indicator of systolic blood pressure less than 99 mm Hg (ref: McManus et al, 2005)

If we are ever out climbing and you find me with a deviated trachea, distended jugular veins, dyspneic and with no radial pulse – stick the needle in my chest.

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