The skill of Needle Thorococentesis (NT) has been a core paramedic skill for many years (Reichman, 2018), used to halt the development of a Tension Pneumothorax (TP). TPs occur in 1 in 250 of major trauma patients, equating to 0.4%, and lead to rapid death if not treated timely and effectively (Leech et al, 2016). TP develops when air enters the pleural cavity without escaping, causing the lung to collapse as air pressure within the thoracic cavity prevents it from inflating: this leads to a ventilation and perfusion (V/Q) mismatch and ultimately cardiac arrest if not rapidly treated [Skinner et al, 2013]. NT describes the process of inserting a cannula though the chest wall into the pleural cavity providing a catheter whereby excess air can escape, reducing intra-pleural pressure and allowing the lung to re-inflate (Gregory and Mursell, 2010). This essay will critically evaluate the skill of NT and make recommendations for future paramedic practice.
The Royal College of Surgeons of Edinburgh (RCSE) (2017) state that NT should be performed in any patient whom a clinician suspects has a TP but also recognises the difficulty in making a TP diagnosis (Leech et al, 2016). Joint Royal Colleges Ambulance Liaison Committee (JRCALC) (2019) guidelines for thoracic trauma advise clinicians to assess for TP within the primary survey of a patient who has suffered thoracic trauma, with symptoms including: poor or no chest movement on the affected side; reduced or absent air entry; distended neck veins; tachycardia and hypotension; tracheal displacement in late stages; and acknowledge that some patients will present only with rapidly deteriorating respiratory distress (JRCALC, 2019). Treatment of TP by NT also forms part of the ‘Hypovolaemia, Oxygenation, Tension Pneumothorax’ (HOT) principles advocated by Lockey et al (2013) in traumatic cardiac arrest, advising NT as a priority reversible cause.
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The thorax contains vital organs and structures therefore it is important for a paramedic to be aware of underlying anatomy and correctly identify landmarks for NT (Wernick et al, 2015); although a study of 51 clinicians did find that 85.2% failed to identify the correct landmarks (Kenny et al, 2016). Current paramedic guidelines advocate 2nd intercostal space, mid-clavicular line (ICS2/MCL) as the primary site of choice for NT, with further attempts in the 5th intercostal space, mid-axilla line (ICS5/MAL) (JRCALC, 2019), also advocated by the RCS (Leech et al, 2016). Caroline and Pilbery (2014) assert the ICS2/MCL is easy to access and has less chance of displacement as patients are generally treated and conveyed in the supine position. The Resuscitation Council (UK) (2015) guidelines state both landmarks can be used and offer no guidance on which the preferred site should be (Deakin et al, 2015). Recent research has offered evidence that ICS5/MAL has a higher chance of success due to a lower mean chest wall thickness (CWT) (Mays, 2016). Laan, et al (2015) concluded that alternative placement sites 4th intercostal space, anterior-axilla line (ICS4/AAL) and ICS5/MAL both had a lower mean CWT of
NT has many documented complications associated with the practice (Wernick, B. et al, 2015). Current guidance advocates using a standard 14g catheter of 4.5cm length for NT (Powers et al, 2015). The Journal of Visualised Experiments (2019) and RCSE (2017) agree with using a large-bore cannula, however the length of the cannula has been shown to influence the success rate of treatment (Blavais, 2010). A study of adult trauma patients demonstrated an average CWT of 3.50cm on the right and 3.51cm on the left at the point of the ICS2/MCL (Zengerink, I. et al, 2008). The study goes onto point out that up to 35.4% of the population studied had a CWT of >4.5cm therefore the 4.5cm cannula length would be unable to penetrate the chest wall and therefore be ineffective at relieving a TP. Harcke, T. et al (2007) agree that a standard length cannula would be ineffective at treating a large percentage of trauma patients indicating a larger mean CWT: they advise that a specialised angiocatheter of 8cm should be used, however their study on male military personnel may not be representative of the population of trauma patients likely to be encountered by civilian paramedics. Schroeder, E. et al (2013) conducted a study of civilian trauma patients and agree with Harke, T. et al (2007) that a standard catheter is inadequate. Aho, J. et al (2016) report success rates of up to 100% using an 8cm catheter but do acknowledge an increase in iatrogenic injury. A meta-analysis performed by Clemency et al (2015) also concludes that a longer catheter of at least 6.44cm is necessary and recommend educating paramedics that not all patients will require the full catheter length to reduce injury.
The National Health Service (NHS) report that obesity affects approximately 1 in 4 adults in the UK (NHS, 2019) and obesity has been shown to be a significant factor in failed NT attempts (Ozen et al, 2016). Carter et al (2013) state a longer needle must be available for use on obese patients and suggest use could be determined by the clinician’s assessment of the individual patient. This is further supported by Powers et al. (2014) who suggest a tool could be developed to estimate appropriate catheter size as CWT directly correlates with weight. It could however be argued that weight is difficult to accurately estimate in the prehospital setting (Leib and Gluckman, 2004), and Britten, S. et al, (1996) disagree with this approach, recommending that should a first NT with a standard cannula fail, it should only then be followed by NT using a longer cannula.
It was noted in several studies that women have a larger mean CWT than men and therefore a standard catheter would fail in a larger percentage of female patients than male (Zengerink, I. et al, 2008), (Laan, D. et al, 2015), (Akoglu et al, 2013) so it could be argued that female patients could be indicated for longer catheters, but Schroeder, E. et al (2013) found no link between sex and CWT. Interestingly, Ozen (2016) reported a higher success rate in ICS2/MCL than ICS5/MAL in female patients, contradicting Laan et al’s (2016) conclusion that ICS5/MAL provided a better chance of success.
Current guidelines offer only one suggested catheter size and length for all patients with no definitive guidance on paediatric NT (Terboven et al, 2019). The Broweslow tape, a tool used to determine equipment sizing and dosages in paediatric trauma emergencies, does not offer guidance on needle size for NT (DeRoss and Vane, 2004). Mandt, M. et al (2019) found a 14g 4.5cm catheter would penetrate the chest wall at ICS2/MCL of all paediatrics
NT can be further complicated by the catheter blocking with blood and/or tissue during insertion (Wernick et al, 2015). Gregory and Mursell (2010) also recognise these common complications, with Escott et al (2014) acknowledging that it is difficult to ascertain if the catheter is blocked or if the TP was initially misdiagnosed. Beckett et al (2011) noted an increase in catheters kinking and thus becoming occluded when placed in a midaxillary line. The National Institute for Health and Care Excellence (NICE) (2015) and Resuscitation Council (UK) (Deakin et al, 2015) highlight the importance of regular reassessment in a patient who has undergone NT for early recognition of these complications as a successfully treated TP may redevelop and require further NT.
It is widely accepted that NT is not intended as a definitive treatment for TP and should only be used as an interim measure while provision is made to insert tube chest drains (Jones and Hollingsworth, 2002). NT is associated with a high failure rate (Kaserer et al, 2017); and Jenkins and Sudheer (2000) advise immediate ST or tube thoracostomy (TT) should NT fail in the first instance. NICE (2015) recommend ST or TT instead of NT if a qualified clinician is available as ST and TT are regarded as more stable than NT. Escott et al (2014) puts forward a case that a paramedic’s skillset could be broadened to include ST for patients in traumatic cardiac arrest with the correct training and a clear set of guidelines. Rottenstreich et al (2015) also identified a need to develop more advanced techniques in the prehospital management of TP but did cite the shorter procedural time and lower risk of infection as potential benefits of NT. Shorter pre-hospital times have shown to be associated with better trauma patient outcome, often referred to as the ‘Golden Hour’ (Swaroop, 2013) but Weichenthal et al (2015) found no significant correlation between survival rates and transport time in patients who had undergone NT. Braude et al (2014) further concluded that neither ST or TT was required for patients travelling by air, and TP could be successfully managed by NT in these cases.
At ICS2/MCL, nerves and arteries run inferior to the 2nd rib and insertion of a needle here can damage these structures (Heng et al, 2004). Several cases of iatrogenic injury have been documented as a result of NT, with the primary cause attributed to dangerous anatomic location (Netto et al, 2007). Zahoor (2015) and Lyndsay (2016) also recount cases of poor NT placement leading to injury. Rawlins et al (2003) and Riwoe and Poncia (2011) further document instances of significant haemorrhage post NT in ICS2/MCL, while Yacovone, Kartan and Bautista (2010) specifies elderly patients as high risk for iatrogenic injury. There is concern that implementation of longer catheters could see an increase in damage to the lung, heart, subclavian and great vessels (Zengerink, 2008).
The Health and Care Professions Council (HCPC) (2014) state registrant paramedics must be competent and safe in practice, emphasising the need for continued up-to-date learning and development. It has been demonstrated that there is a lack of awareness of appropriate site for NT, with many clinicians being unable to correctly identify the landmarks prehospitally (Ferrie, Collum and McGovern, 2005). Equipment has been developed to improve accuracy with anatomic location however it has not yet been trialled in the emergency setting (Shah, Kothera and Dheer, 2019). Blavais et al (2010) ascertained that up to 26% of patients undergoing NT by paramedics had been misdiagnosed with TP, with Kaserer et al (2017) reporting similar findings, indicating a requirement for more extensive training on TP recognition. Warner et al (2008) states many patients who have undergone prehospital NT go on to have TT in hospital, and highlights how unnecessary NT would lead to unnecessary TT, possibly increasing patient morbidity. Such educational programs have been shown to positively influence successful treatment of TP (Cantwell et al, 2014). NT is currently often taught and practiced on simulation mannequin chests leading to unrealistic experiences of identifying landmarks (Boyle et al, 2012) which could account for incorrect placement found by Kenney et al (2016). A progressive training format from mannequin to cadaver simulation was shown to increase clinician’s confidence with placement (Studer et al, 2013), while Kenny et al (2016) found clinicians’ confidence did not correlate with their competence in NT. It is, however, overwhelmingly concluded that NT remains a safe and necessary skill when performed correctly by paramedics (Warner et al, 2008), (Leech et al, 2017), (JRCALC, 2019).
In conclusion, NT remains a necessary, life-saving skill as part of paramedic practice. Further education is required to ensure robust knowledge of patient assessment and indications to improve clinicians’ competence and confidence, thereby reducing error in diagnosis and treatment. Extensive research should be conducted on the introduction of longer catheters with a view to reducing failure rates: cost-effectiveness and complications should be considered. Finally, training in ST and TT could be viewed as a natural progression of paramedic skill, however the author recommends establishing consistent success with NT primarily. This could be achieved by broadening guidance on NT anatomical placement and encouraging critical assessment prior to decision making by paramedics.
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