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Trick of the Trade: Don't miss the pneumothorax in needle thoracostomy

Posted Oct 02 2012 12:00am
A patient arrives in PEA arrest and you note that her left chest has no breath sounds or lung sliding on bedside ultrasound. You suspect a tension pneumothorax.

You insert a standard 14g angiocather in the left 2nd intercostal space (ICS). You don't hear a rush of air. The patient's clinical condition deteriorates to impending asystole. How sure are you that your angiocatheter actually reached the pleural space?

Trick of the Trade #1:
If aiming for the mid-clavicular 2nd ICS, go more lateral than you think. The clavicle ends in the shoulder, not the lateral chest wall! (1)

  • Ferrie et al study: Dots are where emergency physicians would have inserted an angiocatheter. Vertical line is the true mid-clavicular line.

Trick of the Trade #2: 
Insert angiocatheter at the 5th ICS along the mid-axillary line, similar to the location of a chest tube.

  • Cadaver study by Inaba et al (2): Average chest wall thickness was 3.5 cm ± 0.9 cm at mid-axillary 5th ICS vs 4.5 cm ± 1.1 cm at mid-clavicular 2nd ICS
  • Success needle thoracostomy placement was 100% (5th ICS) vs 58% (2nd ICS)
  • Use at least a 5 cm angiocatheter.

Trick of the Trade #3:
Regardless of whether you use the mid-clavicular 2nd ICS or mid-axillary 5th ICS, use a longer angiocatheter than a traditional 3 cm IV angiocatheter. Otherwise it won't reach the pleural space!

  • Example: Use the 6.3 cm angiocatheter often found in central line kits.
  • The average chest wall thickness at the 2nd ICS in a retrospective study in Canada was (3):

Thanks to Dr. Scott Weingart ( @emcrit ). Listen to the podcast for more tips and suggestions on this topic at his  EMCrit blog !


  1. Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J. 2005 Nov;22(11):788-9. Pubmed . Free PDF article
  2. Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011 Nov;71(5):1099-103; discussion 1103. Pubmed
  3. Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008 Jan;64(1):111-4.  Pubmed  

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