TCCC and most EMS protocols list needle thoracostomy as the intervention of choice in the management of a suspected tension pneumothorax.
There is a significant amount of recent, relevant research regarding needle thoracostomy for chest decompression. Three studies examine the question of the optimal site to use for thoracostomy. A cadaver study found that the fifth intercostal, midaxillary site is more consistently accessed versus the second intercostal, midclavicular site (100% successful placement vs 58% respectively). Another found that the anterior site was more reliable, though both were prone to failure. In favor of the anterior site, a military study found the lateral site significantly more prone to occlusion during transport in patients with arms positioned at the sides.
A review from 2008 concluded that needle decompression is unreliable in general, and that blunt thoracostomy should be performed to more definitively manage pneumothorax:
“Blunt dissection and digital decompression through the pleura is the essential first step for pleural decompression, as decompression of the pleural space is a primary goal during reception of the haemodynamically unstable patient with a haemothorax or pneumothorax”
Finger thoracostomy is the approach employed by some Australian HEMS services in traumatic arrest resuscitation. Finger thoracostomy is similar in principle to chest tube insertion, however, no tube is inserted. Instead, an incision is made in the chest wall and the finger inserted, performing blunt dissection through the parietal pleura. The finger is then removed with nothing remaining in the incision. The creation of a vent to the outside environment combined with positive pressure ventilation prevents the accumulation of air in the pleural space.
The literature supports finger thoracostomy as a more definitive approach toward the management of tension pneumothorax when compared to needle thoracostomy. For more on finger thoracostomy, see EmCrit (and here on traumatic arrest) and Resus.ME.
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