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Alvarez M, Evans DD, Tucker P. Spontaneous Pneumothorax: Controversies in Treatment. Adv Emerg Nurs J 2023; 45:169-176. [PMID: 37501266 DOI: 10.1097/tme.0000000000000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
The Research to Practice column critiques a current research article and translates the findings, in the context of a case, to a practice change within emergency settings. This article reviews the findings of a randomized controlled trial conducted by A. Theille et al. (2017) comparing the use of needle decompression versus chest tube insertion for management of spontaneous pneumothorax. The study found that use of needle aspiration was safe and effective and was associated with fewer procedure-related complications and significantly shorter hospital stays. The investigators concluded that needle aspiration be used as a first-line, definitive treatment in management of a spontaneous pneumothorax. As emergency providers examine improved and equally effective approaches to care that are associated with less costs and potential complications, needle aspiration offers a beneficial approach and should be shared with patients when discussing treatment options to ensure shared decision making.
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Affiliation(s)
- Marlen Alvarez
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
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Wang Y, Wang L, Chen C, Que Y, Li Y, Luo J, Yin M, Lv M, Xu G. Safety and Risk Factors of Needle Thoracentesis Decompression in Tension Pneumothorax in Patients over 75 Years Old. Can Respir J 2023; 2023:2602988. [PMID: 37181158 PMCID: PMC10174999 DOI: 10.1155/2023/2602988] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/03/2023] [Accepted: 04/15/2023] [Indexed: 05/16/2023] Open
Abstract
Background There are very few professional recommendations or guidelines on the needle thoracentesis decompression (NTD) for the tension pneumothorax in the elderly. This study aimed to investigate the safety and risk factors of tension pneumothorax NTD in patients over 75 years old based on CT evaluation of the chest wall thickness (CWT). Methods The retrospective study was conducted among 136 in-patients over 75 years old. The CWT and closest depth to vital structure of the second intercostal space at the midclavicular line (second ICS-MCL) and the fifth intercostal space at the midaxillary line (fifth ICS-MAL) were compared as well as the expected failure rates and the incidence of severe complications of different needles. We also analyzed the influence of age, sex, presence or absence of chronic obstructive pulmonary disease (COPD), and body mass index (BMI) on CWT. Results The CWT of the second ICS-MCL was smaller than the fifth ICS-MAL both on the left and the right side (P < 0.05). The success rate associated with a 7 cm needle was significantly higher than a 5 cm needle (P < 0.05), and the incidence of severe complications with a 7 cm needle was significantly less than an 8 cm needle (P < 0.05). The CWT of the second ICS-MCL was significantly correlated with age, sex, presence or absence of COPD, and BMI (P < 0.05), whereas the CWT of the fifth ICS-MAL was significantly correlated with sex and BMI (P < 0.05). Conclusion The second ICS-MCL was recommended as the primary thoracentesis site and a 7 cm needle was advised as preferred needle length for the older patients. Factors such as age, sex, presence or absence of COPD, and BMI should be considered when choosing the appropriate needle length.
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Affiliation(s)
- Yanhu Wang
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Lei Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Cheng Chen
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Yifan Que
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Yinyi Li
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Jiang Luo
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Ming Yin
- Department of Emergency, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Miao Lv
- The Third Medical Center, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
| | - Guogang Xu
- The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing, China
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Hossain R, Qadri U, Dembowski N, Garcia A, Chen L, Cicero MX, Riera A. Sound and Air: Ultrasonographic Measurements of Pediatric Chest Wall Thickness and Implications for Needle Decompression of Tension Pneumothorax. Pediatr Emerg Care 2021; 37:e1544-e1548. [PMID: 32925707 DOI: 10.1097/pec.0000000000002112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Needle decompression is potentially life-saving in cases of tension pneumothorax. Although Advanced Trauma Life Support recommends an 8-cm needle for decompression for adults, no detailed pediatric guidelines exist, specifically regarding needle length or site of decompression. METHODS Point-of-care ultrasound was used to measure chest wall thickness (CWT), the distance between skin and pleural line, bilaterally at the second intercostal midclavicular line and the fourth intercostal anterior axillary line in children of various ages and sizes. Patients were grouped based on Broselow tape weight categories. Measurements were compared between left versus right sides at the 2 anatomic sites. Interclass correlation coefficients were calculated to assess for interrater reliability. RESULTS A convenience sample of 163 patients from our emergency department was enrolled. For patients who fit into Broselow tape categories, CWT at the second intercostal midclavicular line ranged from 1.11 to 1.91 cm and at the fourth intercostal anterior axillary line ranged from 1.13 to 1.92 cm. In patients larger than the largest Broselow category, 77% had a CWT less than the length of a standard 1.25-in (3.175 cm) catheter. There were no significant differences in the measurements of CWT based on laterality nor anatomic site. CONCLUSIONS The standard 1.25-in (3.175 cm) catheters are sufficient to treat most tension pneumothoraces in pediatric patients.
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Affiliation(s)
| | | | | | - Angelica Garcia
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Lei Chen
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Mark X Cicero
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Antonio Riera
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
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Lyng J, Adelgais K, Alter R, Beal J, Chung B, Gross T, Minkler M, Moore B, Stebbins T, Vance S, Williams K, Yee A. Recommended Essential Equipment for Basic Life Support and Advanced Life Support Ground Ambulances 2020: A Joint Position Statement. Pediatrics 2021; 147:peds.2021-051508. [PMID: 34011633 DOI: 10.1542/peds.2021-051508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- John Lyng
- National Association of EMS Physicians, Overland Park, Kansas;
| | - Kathleen Adelgais
- Emergency Medical Services for Children Innovation and Improvement Center, Austin, Texas
| | - Rachael Alter
- Emergency Medical Services for Children Innovation and Improvement Center, Austin, Texas
| | - Justin Beal
- Emergency Nurses Association, Des Plaines, Illinois
| | - Bruce Chung
- American College of Surgeons Committee on Trauma, Chicago, Illinois
| | - Toni Gross
- National Association of EMS Physicians, Overland Park, Kansas
| | - Marc Minkler
- National Association of State Emergency Medical Services Officials, Falls Church, Virginia; and
| | - Brian Moore
- American Academy of Pediatrics, Itasca, Illinois
| | - Tim Stebbins
- National Association of EMS Physicians, Overland Park, Kansas
| | - Sam Vance
- Emergency Medical Services for Children Innovation and Improvement Center, Austin, Texas
| | - Ken Williams
- National Association of State Emergency Medical Services Officials, Falls Church, Virginia; and
| | - Allen Yee
- National Association of EMS Physicians, Overland Park, Kansas
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Terboven T, Betka I, Weiss C, Rudolph M, Viergutz T, Leonhard G, Schöler M. Sonographic assessment of pediatric chest wall thickness and width of the intercostal space: correlation with anthropometric data and implications for needle decompression. Ultrasound J 2021; 13:25. [PMID: 33970385 PMCID: PMC8110626 DOI: 10.1186/s13089-021-00226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Emergent needle decompression in children is a rare event for emergency medicine and critical care providers. Hereby, risk of injury of intrathoracic structures is high and knowledge of age-specific values of chest wall thickness and width of the intercostal space (ICS) is crucial to avoid injuries. Investigation of the correlation of chest wall thickness and width of the intercostal space with age and body dimension like weight and height could provide guidance on depth of insertion and choice of the needle. Methods We performed a prospective observational clinical trial in a pediatric surgery operating room that included a convenient sample of children aged 0–10 years undergoing elective surgery. Chest wall thickness and width of the intercostal space were measured with ultrasound at 2nd ICS midclavicular line (MCL) and 4th ICS anterior axillary line (AAL). Correlation of these measures with age, height, weight, BMI and Broselow color was calculated. Furthermore, intra-class correlation coefficient was calculated as a measure of reproducibility and the presence of vital structures (e.g., heart, thymus gland, large pulmonary vessels) at the possible insertion sites for needle decompression was investigated. Results Of 410 potentially eligible patients, 300 were included in the study. Correlation of chest wall thickness was moderate with weight (2nd ICS MCL: r = 0.57; 4th ICS MCL: r = 0.64) and BMI (r = 0.44 and r = 0.6) and was lower with age (r = 0.38 for both intercostal spaces), height (r = 0.42 and r = 0.40) and Broselow color (r = 0.42 and r = 0.38). Correlation of width of the ICS with anthropometric data was generally stronger, with height showing the strongest, albeit not really strong, correlation (r = 0.71 and r = 0.62). Intra-class correlation was excellent with an ICC of 0.93. Vital structures were significantly more often present at 2nd ICS MCL then at 4th ICS AAL (14 vs. 2 patients; p = 0.0042). Conclusions Correlation of chest wall thickness and width of the intercostal space with anthropometric data is at most moderate. Insertion depth and width of the intercostal space can therefore not be predicted accurately from anthropometric data. Ultrasound assessment of the thoracic wall appears to be a reliable technique and could therefore assist in reducing the risk of injury and increasing decompression success. Trial registration German clinical trials register, DRKS00014973, Registered February 11th 2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014973 Supplementary Information The online version contains supplementary material available at 10.1186/s13089-021-00226-6.
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Affiliation(s)
- Tom Terboven
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ivette Betka
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christel Weiss
- Department of Medical Statistics, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Marcus Rudolph
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,DRF Stiftung Luftrettung gemeinnützige AG, Filderstadt, Germany
| | - Tim Viergutz
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Georg Leonhard
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Michael Schöler
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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[Prehospital treatment of tension pneumothorax in children-which decisions do we make? : Results of a survey among German emergency physicians]. Anaesthesist 2021; 70:928-936. [PMID: 33891124 DOI: 10.1007/s00101-021-00966-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/04/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The preclinical treatment of a traumatic or spontaneous tension pneumothorax remains a particular challenge in pediatric patients. Currently recommended interventions for decompression are either finger thoracostomy or needle decompression. Due to the tiny intercostal spaces, finger thoracostomy may not be feasible in small children and surgical preparation may be necessary. In needle decompression, the risk of injuring underlying vital structures is increased because of the smaller anatomic structures. As most emergency physicians do not regularly work in pediatric trauma care, decompression of tension pneumothorax is associated with significant uncertainty; however, in this rare emergency situation, consistent and goal-oriented action is mandatory and lifesaving. An assessment of pre-existing experience and commonly used techniques therefore seems necessary to deduce the need for future education and training. OBJECTIVE In this study an online survey was created to evaluate the experience and the favored prehospital treatment of tension pneumothorax in children among German emergency physicians. MATERIAL AND METHODS An online survey was conducted with 43 questions on previous experience with tension pneumothorax in children, favored decompression technique and anatomical structures in different age groups. Surveyed were the emergency physicians of the ground-based emergency medical service of the University Medical Center Mannheim, the German Air Rescue Service (DRF) and the pediatric emergency medical service of the City of Munich. RESULTS More than half of all respondents stated that there was uncertainty about the procedure of choice. Needle decompression was favored in smaller children and mini-thoracostomy in older children. In comparison with the literature, the thickness of the chest wall was mostly estimated correctly by the emergency medical physicians. The depth of the vital structures was underestimated at most of the possible insertion sites in all age groups. At the lateral insertion sites on the left hemithorax, however, the distance to the left ventricle was overestimated. The caliber of the needle selected for decompression tended to be too large, especially in younger children. CONCLUSION Even though having interviewed an experienced group of prehospital emergency physicians, the experience in decompression of tension pneumothorax in children is relatively scant. Knowledge of chest wall thickness and depth to vital structures is sufficient, the choice of needle calibers tends to be too large but still reasonable. For many providers a large amount of uncertainty about the right choice of technique and equipment arises from the challenge of decompressing a tension pneumothorax in children and therefore further theoretical education and regular training are required for safe performance of the procedure.
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Lyng J, Adelgais K, Alter R, Beal J, Chung B, Gross T, Minkler M, Moore B, Stebbins T, Vance S, Williams K, Yee A. Recommended Essential Equipment for Basic Life Support and Advanced Life Support Ground Ambulances 2020: A Joint Position Statement. PREHOSP EMERG CARE 2021; 25:451-459. [PMID: 33557659 DOI: 10.1080/10903127.2021.1886382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In continued support of establishing and maintaining a foundation for standards of care, our organizations remain committed to periodic review and revision of this position statement. This latest revision was created based on a structured review of the National Model EMS Clinical Guidelines Version 2.2 in order to identify the equipment items necessary to deliver the care defined by those guidelines. In addition, in order to ensure congruity with national definitions of provider scope of practice, the list is differentiated into BLS and ALS levels of service utilizing the National Scope of Practice-defined levels of Emergency Medical Responder (EMR) and Emergency Medical Technician (EMT) as BLS, and Advanced EMT (AEMT) and Paramedic as ALS. Equipment items listed within each category were cross-checked against recommended scopes of practice for each level in order to ensure they were appropriately dichotomized to BLS or ALS levels of care. Some items may be considered optional at the local level as determined by agency-defined scope of practice and applicable clinical guidelines. In addition to the items included in this position statement our organizations agree that all EMS service programs should carry equipment and supplies in quantities as determined by the medical director and appropriate to the agency's level of care and available certified EMS personnel and as established in the agency's approved protocols.
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Leonhard G, Overhoff D, Wessel L, Viergutz T, Rudolph M, Schöler M, Haubenreisser H, Terboven T. Determining optimal needle size for decompression of tension pneumothorax in children - a CT-based study. Scand J Trauma Resusc Emerg Med 2019; 27:90. [PMID: 31604472 PMCID: PMC6788035 DOI: 10.1186/s13049-019-0671-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background For neonates and children requiring decompression of tension pneumothorax, specific recommendations for the choice of needle type and size are missing. The aim of this retrospective study was to determine optimal length and diameter of needles for decompression of tension pneumothorax in paediatric patients. Methods Utilizing computed tomography, we determined optimal length and diameter of needles to enable successful decompression and at the same time minimize risk of injury to intrathoracic structures and the intercostal vessels and nerve. Preexisting computed tomography scans of the chest were reviewed in children aged 0, 5 and 10 years. Chest wall thickness and width of the intercostal space were measured at the 4th intercostal space at the anterior axillary line (AAL) on both sides of the thorax. In each age group, three needles different in bore and length were evaluated regarding sufficient length for decompression and risk of injury to intrathoracic organs and the intercostal vessels and nerve. Results 197 CT-scans were reviewed, of which 58 were excluded, resulting in a study population of 139 children and 278 measurements. Width of the intercostal space was small at 4th ICS AAL (0 years: 0.44 ± 0.13 cm; 5 years: 0.78 ± 0.22 cm; 10 years: 1.12 ± 0.36 cm). The ratio of decompression failure to risk of injury at 4th ICS AAL was most favourable for a 22G/2.5 cm catheter in infants (Decompression failure: right: 2%, left: 4%, Risk of injury: right: 14%, left: 24%), a 22G/2.5 cm or a 20G/3.2 cm catheter in 5-year-old children (20G/3.2 cm: Decompression failure: right: 2.1%, left: 0%, Risk of injury: right: 2.1%, left: 17%) and a 18G/4.5 cm needle in 10-year-old children (Decompression failure: right: 9.5%, left: 9.5%, Risk of injury: right: 7.1%, left: 11.9%). Conclusions In children aged 0, 5 and 10 years presenting with a tension pneumothorax, we recommend 22G/2.5 cm, 20G/3.2 cm and 18G/4.5 cm needles, respectively, for acute decompression.
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Affiliation(s)
- Georg Leonhard
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Daniel Overhoff
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Lucas Wessel
- Department of Paediatric Surgery, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Tim Viergutz
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Marcus Rudolph
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,DRF Stiftung Luftrettung gemeinnützige AG, Filderstadt, Germany
| | - Michael Schöler
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Holger Haubenreisser
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Tom Terboven
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Terboven T, Leonhard G, Wessel L, Viergutz T, Rudolph M, Schöler M, Weis M, Haubenreisser H. Chest wall thickness and depth to vital structures in paediatric patients - implications for prehospital needle decompression of tension pneumothorax. Scand J Trauma Resusc Emerg Med 2019; 27:45. [PMID: 30992028 PMCID: PMC6469218 DOI: 10.1186/s13049-019-0623-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 03/26/2019] [Indexed: 11/20/2022] Open
Abstract
Background Recommendations regarding decompression of tension pneumothorax in small children are scarce and mainly transferred from the adult literature without existing evidence for the paediatric population. This CT-based study evaluates chest wall thickness, width of the intercostal space (ICS) and risk of injury to vital structures by needle decompression in children. Methods Chest wall thickness, width of the intercostal space and depth to vital structures were measured and evaluated at 2nd ICS midclavicular (MCL) line and 4th ICS anterior axillary line (AAL) on both sides of the thorax using computed tomography (CT) in 139 children in three different age groups (0, 5, 10 years). Results Width of the intercostal space was significantly smaller at the 4th ICS compared to the 2nd ICS in all age groups on both sides of the thorax. Chest wall thickness was marginally smaller at the 4th ICS compared to the 2nd ICS in infants and significantly smaller at 4th ICS in children aged 5 years and 10 years. Depth to vital structure for correct angle of needle entry was smaller at the 4th ICS in all age groups on both sides of the thorax. Incorrect angle of needle entry however is accompanied by a higher risk of injury at 2nd ICS. Furthermore, in some children aged 0 and 5 years, the heart or the thymus gland were found directly adjacent to the thoracic wall at 2nd ICS midclavicular line. Conclusion Especially in small children risk of iatrogenic injury to vital structures by needle decompression is considerably high. The 4th ICS AAL offers a smaller chest wall thickness, but the width of the ICS is smaller and the risk of injury to the intercostal vessels and nerve is greater. Deviations from correct angle of entry however are accompanied by higher risk of injury to intrathoracic structures at the 2nd ICS. Furthermore, we found the heart and the thymus gland to be directly adjacent to the thoracic wall at the 2nd ICS MCL in a few children. From our point of view this puncture site can therefore not be recommended for decompression in small children. We therefore recommend 4th ICS AAL as the primary site of choice. Electronic supplementary material The online version of this article (10.1186/s13049-019-0623-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tom Terboven
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Georg Leonhard
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Lucas Wessel
- Department of Paediatric Surgery, Mannheim University Medical Center, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Tim Viergutz
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Marcus Rudolph
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,DRF Stiftung Luftrettung gemeinnützige AG, Filderstadt, Germany
| | - Michael Schöler
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Meike Weis
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Holger Haubenreisser
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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