Should we consider the use of alternative sites for needle thoracostomy?

In the absence of advanced practitioners on scene, needle thoracostomy (NT) is the only treatment modality currently widely available to paramedics in order to relieve tension pneumothorax. Both ATLS and JRCALC guidelines (Association of Ambulance Chief Executives, 2013) recommend that for NT, a cannula be placed at the second intercostal space at the mid-clavicular line (ICS2-MCL). This paper, however, cites a number of difficulties associated with NT at this site, namely, variable chest wall thickness (CWT) and inability of practitioners to identify the correct anatomical location. Commonly used alternative sites consist of the 4^th/5^th intercostal space, mid axillary line (ICS4/5-MAL) and 4^th/5^th intercostal space, anterior axillary line (ICS 4/5-AAL).

The researchers conducted a literature review to determine a sufficiently powered mean of CWT at the three possible insertion sites (ICS2-MAL, ICS4/5-MAL, ICS4/5-AAL). They also searched for studies of failure rates for NT. This systematic review followed standards for PRISMA (Preferred Reported Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analysis of Observational Studies in Epidemiology). A literature search was conducted using multiple databases from the point they first became available up to 24 July 2014. Studies on CWT must have determined CWT using either computer tomography or by direct means using a cadaver. NT studies were required to use a 5 cm angiocatheter only.