Thoracentesis in emergency

[Filius Mariae]

Hi everyone, I hope I'm not repeating an old question and have asked in the right place.

I've just started my thorax anatomy in Med 1 and needle thoracentesis is introduced in Moore to tackle pneumothorax. The professor mentioned that thoracentesis could be performed without proper needles to relieve tension pneumothorax. For instance a ball pen could also be used to 'stab' into the patient.

Questions: given the relatively large diameter of ball pen compared to needle, and the fact that no proper catheter is present, how could the pen be inserted without damaging the three layers of intercostal muscles? Will muscle fibre necrosis occur as a complication? How to safely perform thoracentesis on patients in case there really is no proper 14G needle without catheter and three-way stopcock?

I hope my question won't appear too stupid. Thank you!

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[winkleweizen]

If youre opening up the guys chest because he has a tension ptx, the last thing we are thinking about is damaging the intercoastal muscles, plus you would follow it up with a chest tube anyway which is much bigger than a ball pt pen.


I also don't know about most people now a days, but we tend to just " vent" the patients chest with a scalpel as opposed to needle decompression.

 

[WilcoWorld]

Agree that the intercostal muscles are not the primary concern in a life-threatening situation. But if you're coming at me MacGuyver style, please use a sharp knife to make the whole and then stick the pen tube minus the ink cartridge through the hole…then get me to a hospital and get me some antibiotics and a real chest tube!

But back to your basic-science question: if you're going to worry about damaging structures during this procedure what you should be really worrying about is the intercostal neurovascular bundle - those can bleed pretty briskly. As such, go just superior to the rib aka at the inferior margin of the intercostal space.

 

[e30ftw]

fwiw you describe a needle thoracostomy, or in your professor's case, "pen thoracostomy" not a thoracentesis.

the literature i have reviewed does not support using standard IV caths (even 14 guage) for needle decompression. it is unsuccessful in up to 40% of cases even with recommended ATLS 5 cm angiocaths 2/2 body habitus, poor training in proper location, etc.

if i had a moribund pt with obvious tension ptx physiology in front of me and only a needle i would insert in 4/5 intercostal mid axillary space not mid clavicular.

if you have more than 5 seconds for the procedure it's probably better to prep/incise/bluntdissect/kelly-it into the pleural space ie: finger or traditional thoracostomy than using a cath which is temporary, can kink, can be dislodged, etc.

these patients are typically moribund and there isn't a lot you can do to help/hurt them. If you have someone in hypovolemic shock w/ MS changes and mild hypotension but still maintaining airway w/ vital signs just quickly place a chest tube per standard technique.