Thursday, January 7, 2016

We Don't Know the Midclavicular Line

The Gist:  Needle decompression for tension pneumothorax should be taught at the fourth or fifth intercostal space at the anterior axillary line (4/5ICS AAL). 

  • Note: This post will not detail critiques that needle decompression may be overused or the needle vs thoracostomy debate.

Historical teaching instructs providers to place a needle in the second ICS at the mid-clavicular line (2ICS MCL) for tension pneumothorax [1,2]. Free Open Access Medical Education (FOAM) sources such as Emergency Medicine Ireland have preached the more lateral approach for years; yet this teaching has not spread widely (outside of military circles where there seems to be better adoption). Change is difficult, particularly when it involves re-educating thousands of providers and it seems like this is the primary driver behind the 2ICS MCL remaining as the typical site for needle decompression..  However, several potential problems exist with the mid-clavicular approach that warrant consideration for assuming 4/5ICS AAL as the primary initial placement for needle decompression.

A: Where I see most needles placed, B: 2ICS MCL, C: 5ICS AAL
We may not be able to reach the pleura [3-5].  The chest wall may be particularly thick at the 2ICS MCL, particularly as the average BMI in many nations grows.  Researchers have looked at this question for years through a couple of means - measuring the depth at the 2ICS MCL on CT scans of trauma patients compared with alternative sites. The 2ICS MCL is generally 1.3 cm thicker than 5ICS AAL. 
  • This discrepancy was not solely seen in the morbidly obese.  In fact, it was seen consistently across all four BMI quartiles tested, and at the traditional insertion site, needle decompression would have been extremely difficult with any eccentric placement using a standard needle in all but the lowest BMI quartile [3].
How often would the needle fail?  A systematic review and meta-analysis in Injury 2015 by Laan et al looked at 17 studies, generally cadaveric or radiographic, and found that a standard 5 cm catheter used for needle decompression at the 2ICS MCL would fail 38% (24–54%) of the time compared with only 13% (8–22%) at ICS4/5-AAL (p= .01) [5].
  • The British Thoracic Society Guidelines (2010) even remark “a standard 14 gauge (4.5 cm) cannula may not be long enough to penetrate the parietal pleura..with up to one-third of patients having a chest wall thickness >5 cm in the second interspace.”
  • In some places, the failure rate may be even higher secondary to obesity [5].
What about a longer needle?  Many catheters used for needle decompression are 5 cm in length; however, some have access to 8 cm angiocatheters.  A analysis by Clemency and colleagues found that in order to achieve a success rate of 95%, we would need a catheter at lease 6.4 cm in length [8].  Similarly, Laan and colleagues conducted a pre-post retrospective study in an EMS system that switched from using 5 cm catheters to 8 cm catheters with an increase in success rate (48% vs 83%) [6].  For a life saving, last ditch effort, I'm not sure that 95% success rate is adequate when alternatives exist.

We don’t identify this site well [10,11].  A 2005 paper by Ferrie and colleagues had 25 emergency physicians name the correct side for needle thoracentesis and label this site with a pen on a male volunteer (erased between providers).  Nearly all participants were ATLS certified within the past 10 years.  
  • 88% (n=22) named the correct site (one additional person did name the 5ICS AAL).
  • Only 15 of the 25 participants (60%) could correctly identify the 2ICS MCL [10].   
In another study, Inaba and colleagues trained 25 US Navy corpsmen on needle decompression, using both the 2ICS MCL and the 5ICS AAL. The corpsmen then performed needle decompression at both sites on randomly selected cadavers, bilaterally.  
  • Mean distance from the correct location: 3.1 cm 2ICS MCL vs 1.2 cm 5ICS AAL
  • Correct placement (ICS +/- 5 cm):  15/50 (30%) 2ICS MCL vs 41/50 (82%) 5ICS AAL
  • Limitations: This study had multiple outcomes and no power analysis was performed [11]
I think much of this is because we underestimate the length of the clavicle.  It's easier when you can see the chest wall bones but we don't have this advantage in the clinical setting.  On a person, the midclavicular line often seems fairly lateral.  


Important structures surround the 2ICS MCL.  As mentioned above, we seem to have a tough time finding the 2ICS MCL [8,9]. There are important structures in this vicinity, particularly if the tendency is to go more medial than the actual midclavicular line, including the internal mammary artery and contents of the superior mediastinum.  Naturally, should an individual placing a needle in the 4/5ICS AAL go too caudal the possibility exists for the needle to enter the liver or spleen but the study by Inaba and colleagues suggest we may be better able to identify this space [9].

Given the literature, it seems that at this time should a needle be placed aiming for the 2ICS MCL for needle decompression and fail, this is a failure of education and changing our knowledge base rather than a patient-based failure. We should know better.

References:

  1. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl 2):ii18–ii31.
  2. Advanced Trauma Life Support, 9th ed. 
  3. Inaba K, Ives C, McClure K, Branco BC, Eckstein M, ShatzD, Martin MJ, Reddy S, Demetriades D. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012;147(9): 813Y818.
  4. 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. JTrauma. 2011;71(5):1099Y1103; discussion 103.
  5. Laan D V., Vu TDN, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2015:14–16. 
  6.  Laan D, Berns KS, Habermann EB. Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. 2015. doi:10.1097/TA.0000000000000889.
  7. Hecker M, Hegenscheid K, V√∂lzke H, et al. Needle decompression of tension pneumothorax. J Trauma Acute Care Surg. 2016;80(1):119–124. doi:10.1097/TA.0000000000000878.
  8. Carter TE, et al. Needle Decompression in Appalachia Do Obese Patients Need Longer Needles? West J Emerg Med, 2013; 14(6): 650–2
  9. Clemency BM, Tanski CT, Rosenberg M, May PR, Consiglio JD, Lindstrom HA. Sufficient catheter length for pneumothorax needle decompression: a meta-analysis. Prehospital and disaster medicine. 30(3):249-53. 2015.
  10. Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J. 2005;22(11):788–789.
  11. Inaba K, Karamanos E, Skiada D, et al. Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers.

24 comments:

  1. I will like to use this medium to tell those who have sexual problems (ED, Premature Ejaculation, Weak Erection and more) that there is complete cure to it. I have been a victim of many online Doctors who claim to cure everything but took advantage of my predicament to get my money. Erectile Dysfunction(impotence) is an embarrassing problem in all men life, I hide it for long. After so many years of using different medication with no positive result, this is just a true testimony that Dr.Leonard have cured me completely, I can now perform better in bed (sexually active). So if you have the same sexual problem(Erectile Dysfuction) contact drleonard288@gmail.com, for advice and necessary solution.

    ReplyDelete


  2. There are so many solutions are present in the market but no one is perfect. There is no way to prevent appendicitis. However, appendicitis is less common in people who eat foods high in fiber, such as fresh fruits and vegetables. But we provide to you the best Home Remedies For Appendicitis causes no side effects as it is natural.

    ReplyDelete
  3. Shame the above Spam got through. I agree many people go a bit too medial and are scared to put the needle in. Also the concept of the second intercostal space can be confusing too - http://www.rnceus.com/resp/respthoracic.html helped me figure it out!

    ReplyDelete
  4. Most companies publish a mission statement to let the world know what they are striving for as a company. That's important, but, as important is what the company does to make sure all of their employees are focused on bringing the mission statement to life. See more lmu essay

    ReplyDelete

  5. Finally a mother.
    For 8 years my husband and i tried ceaselessly to conceive to no avail. The gynecologist told us that the Fibroid is causing difficulties and he recommended a surgery. I love my life so much and i did't want to undergo any surgery because i was told it's too painful and also there are 80% of it growing back. I was discussing this with a close colleague who told me how Dr Aleta helped her cousin cure fibroid. I contacted her and she was so amazing with encouragements and finally sent me a very effective medicine that changed my life for good. It has been four years now and i am still very fine and i have son i call my own naturally. You too can reach her too on aletedwin@gmail.com for her medicine.

    ReplyDelete
  6. ALL THANKS TO DR WILLIAMS FOR GETTING MY WIFE OUT OF FIBROID WITH HIS HERB One of the greatest moments in this world is when you see your own wife put to bed, this awesome moments makes you a man and not just a man a real man. My wife suffered from Fibroid which made her unable to get pregnant and give us a child for almost 18 years with multiple surgeries done and none seemed to help the situation. I almost gave up but due to the love i had for her because i married her a virgin i had to find a way to help her. I told a member of my church who recommended Dr. williams to me, i contacted her and she sent me a medicine and this medicine shrinked it naturally in weeks it was like magic but it's science. I am happy writing this because she delivered yesterday a baby girl. Do not loose hope too soon contact her on drwilliams098765@gmail.com and i am confident she will help you too.

    ReplyDelete
  7. ALL THANKS TO DR WILLIAMS.
    For 8 years my husband and i tried ceaselessly to conceive to no avail. The gynecologist told us that the Fibroid is causing difficulties and he recommended a surgery. I love my life so much and i did't want to undergo any surgery because i was told it's too painful and also there are 80% chances of it growing back. I was discussing this with a close colleague who told me how Dr williams helped her cousin cure fibroid. I contacted him and he was so amazing with encouragements and finally sent me a very effective medicine that changed my life for good. It has been four years now and i am still very fine and i have son i call my own naturally. You too can reach him too on drwilliams098765@gmail.com for his medicine

    ReplyDelete
  8. ALL THANKS TO DR WILLIAMS FOR GETTING MY WIFE OUT OF FIBROID WITH HIS HERB One of the greatest moments in this world is when you see your own wife put to bed, this awesome moments makes you a man and not just a man a real man. My wife suffered from Fibroid which made her unable to get pregnant and give us a child for almost 18 years with multiple surgeries done and none seemed to help the situation. I almost gave up but due to the love i had for her because i married her a virgin i had to find a way to help her. I told a member of my church who recommended Dr. williams to me, i contacted him and he sent me a medicine and this medicine shrinked it naturally in a weeks it was like magic but it's science. I am happy writing this because he delivered a baby girl. Do not loose hope too soon contact him on drwilliams098765@gmail.com and i am confident she will help you too.

    ReplyDelete
  9. Today has being the most happiest day of my life after 1 year of sadness and sorrow without being with the one i love, i tried all my possible best to make sure i make my lover happy but it never seems to work out well it was like am doing everything in vain but all thanks to Dr Ogudugu for coming to change all my worries and sadness to Joy. I knew the great man when i read some wonderful reviews about Him how he has helped a lots of people on there relationship problem i was reading a magazine which then i saw great testimonies as well which then i decided not to waste time. He told me not to worry that he assures me that within 48 hours everything would be sorted out i believed Dr Ogudugu so much because i believe he can't fail me and i sent him all my details. Truly Dr Ogudugu never failed me,my husband who left me for good a year come back to me. My husband and i have been living contentedly since this spell caster reunited us together with his love spells. Thank you so so so much Dr Ogudugu for your powerful spells. Expressions are not sufficient to say thank you, here is his email address GREATOGUDUGU@GMAIL.COM he can be of help to you on any problem like
    {1} HIV/AIDS
    {2CANCER
    {3}HERPES
    {4}DIABETES
    (5}HERPERTITIS B
    (6}HPV

    http://greatdrogudugusolutiontemple.webs.com/

    ReplyDelete
  10. This article is dedicated to the Doctor Osemu Okpamen. I have been married with my wife for 5 years and recently she broke up with me and it hurt me deeply when she told me to leave her alone and that she does not love me anymore when i was always faithful and honest to her. I tried all the ways to get her back buying her what she wants like i always did and she still left me heart broken and she even has a new boyfriend which destroyed me even more until a friend of mine from high school directed me to this genuine spell Doctor called Osemu Okpamen. This man changed my life completely. I followed everything he told me to do and my wife came back begging for me back. I had faith in everything he told me. Also he was there every moment until i got my happiness back and he also provides spells that cures impotence, bareness, diseases such as HIV/AID E.T.C. You can contact him via email at { Doctorokpamenspelltemple@yahoo.com } or call me for more info +1 (914)-517-3229.

    ReplyDelete
  11. ALL THANKS TO DR WILLIAMS FOR GETTING MY WIFE OUT OF FIBROID WITH HIS HERB One of the greatest moments in this world is when you see your own wife put to bed, this awesome moments makes you a man and not just a man a real man. My wife suffered from Fibroid which made her unable to get pregnant and give us a child for almost 18 years with multiple surgeries done and none seemed to help the situation. I almost gave up but due to the love i had for her because i married her a virgin i had to find a way to help her. I told a member of my church who recommended Dr. williams to me, i contacted him and he sent me a medicine and this medicine shrinked it naturally in a weeks it was like magic but it’s science. I am happy writing this because he delivered a baby girl. Do not loose hope too soon contact him on drwilliams098765@gmail.com and i am confident she will help you too.

    ReplyDelete
  12. My daughter suffered from a terrible tinnitus for more than 23 years which
    started after she turned 5 we all thought it will end but got even worse as
    days went by. We tried all several treatments and therapy prescribed by
    various doctors we met but to no avail, she lost total concentration and
    screamed most times. She usually tells me she hears hissing and ringing
    noises. This were steady noise that disrupted her entire life, even at
    night she screams even more because the sounds become louder because
    everywhere is quiet and she slept less because of this. I was able to
    contact Dr.lewishill. on the matter and his medicine was able to restore
    her back to normal and she is very okay now without any side effects
    whatsoever. If you have Tinnitus, do not hesitate to contact him on
    drlewishill247@gmail.com for advice and for his product. I hope this helps
    someone out there.

    ReplyDelete
  13. ALL THANKS TO DR WILLIAMS.
    For 8 years my husband and i tried ceaselessly to conceive to no avail. The gynecologist told us that the Fibroid is causing difficulties and he recommended a surgery. I love my life so much and i did't want to undergo any surgery because i was told it's too painful and also there are 80% chances of it growing back. I was discussing this with a close colleague who told me how Dr williams helped her cousin cure fibroid and fallopian tube blockage. I contacted him and he was so amazing with encouragements and finally sent me a very effective medicine that changed my life for good. It has been four years now and i am still very fine and i have son i call my own naturally. You too can reach him too on drwilliams098765@gmail.com for his medicine

    ReplyDelete
  14. Hello!! I’m indeed very happy for the great help that Dr. okorom rendered to me, I was a herpes patient my husband also was a herpes patient, we saw a blog whereby Dr. okorom cured herpes, we (Me and My Husband) decided to contact him which we did, he asked us to buy some items, unfailingly we sent him the money he will need in buying the items required, He castes the spell and asked us to go for check-up after three days of casting the spell, Luckily for us we were tested herpes negative, now I believe all these Testimonies about him on the internet, he is truly a great man, if you want to discuss with me on how he cured us, kindly email me on deanfneilsarah@gmail.com or you can contact the great Herbalist and a spell caster on dr.okoromspellhome@live.com or you can call him via his mobile phone number on +2348158168556

    ReplyDelete
  15. I got married to my lovely husband for the past 7 years without conceiving and fibroid was the issue, i took different prescribed medication but could not cure it but my husband was so confident in me and kept encouraging me that one day someone would call me mother, we did not rest searching for solution from different Doctors all they could say was surgery and i was afraid of that then a friend in my office introduced me to Dr. Davismartin who sent his product to me which i took and it really worked perfectly, and my Dr. confirm me pregnant after 2 months of taken his product. i gave birth to a BABY GIRL February this year and i will named her TESTIMONY. contact him also at drdavismartin62@gmail.com.

    ReplyDelete
  16. thankes to Dr ebhota, who cured me of fallopian tube blockage and fibroid. i married for over eight years wthout a child of my own. because of the problem with my fallopian tubbe and fibroid, until i came in conntact with Dr ebhota's testimony and recommendations online, on how he has cured and healed so many people of the same illment, and i decided to contact him, and he administered his medicatons on me, and i became pregnant in two months. increase you want to reach him for a similar problem, you can reach him on +2347086564868 or email him,drebhota123456@gmail.com

    ReplyDelete
  17. ALL THANKS TO DR WILLIAMS WITH HIS HERBAL PORTION I WAS COMPLETELY CURED FROM FIBROID
    I can’t believe this. A great testimony that i must share to all fibroid patient in the world. i never believed that their could be any complete cure for fibroid with out going for surgery ,i saw people’s testimony on blog sites and Facebook page of how Dr williams prepare herbal cure for diferent king of disease,and with the help of his herb they where able to shrink there fibroid naturally. i had to try it too and you can,t believe that in just few weeks i started using it all my pains stop gradually . Right now i want to tell you all that i just give birth to a baby boy last month,and on thin now i have not had any pain, and i have just went for text last week and the doctor confirmed that there is no trace of any fibroid in my system . Glory be to God for leading me to this great Dr williams I am so happy as i am sharing this testimony. My advice to you all who thinks that their is no herbal cure for fibroid that is Not true ,just contact him and get cure from his email drwilliams098765@gmail.com and you will be free and free forever, Try it and you will not regret it because it truly works. i hope to see your testimony soon.

    ReplyDelete
  18. Hello,i am From United Kingdom. I wish to share my testimonies with the general public about what this man called Dr Agbebaku has just done for me , this man has just brought back my lost Ex husband to me with his great spell, I was married to this man called smith joe we were together for a long time and we loved our self’s but when I was unable to give him a child for 2 years he left me and told me he can’t continue anymore then I was now looking for ways to get him back until a friend of mine told me about this man and gave his contact email(dragbebakuspelltemple@gmail.com) then you won’t believe this, when I contacted this man on my problems he prepared this spell cast. and bring my lost husband back, and after a month I miss my monthly period and i go for a test and the result stated am pregnant. am happy today am a mother of a baby girl, thank you once again the great DR Agbebaku for what you have done for me, if you are out there passing through any of this problems listed below: you can contact him via Email; dragbebakuspelltemple@gmail.com (1) If you want your ex back. (2) if you always have bad dreams. (3) You want to be promoted in your office. (4) You want women/men to run after you. (5) If you want a child. (6) You want to be rich. (7) You want to tie your husband/wife to be yours forever. (8) Or you have been scammed and you want to recover your lost money contact him now (dragbebakuspelltemple@gmail.com) My Name is happiness joe From United Kingdom, see more at https://dragbebakuherbalho.wixsite.com/solutioncenter

    ReplyDelete

  19. I am Matthias lang, from Orlando u s a, i was diagnosed with FIBROID for 6 years, i lived in pain with the knowledge that i wasn't going to ever give birth, i contacted so many doctors on this issue,and i have use so many western drugs prescribe by various doctors and all was no avail, because i was determined to get my life back, one day i was researching for this on internet and i saw a post about devansh herbal health care who cure different manners of diseases, including fibroid, I contacted them via email: devanshherbalheathcare@gmail.com and made purchase of the fibroid herb, i received the herb through USPS within 24 hours, when i received the herb i applied it as prescribed and i was totally cured of fibroid within 1 months of usages,and to god be the glory i give birth to a baby boy,and on thin now i have never experience any pain in my body again,few days later i went back to my doctor and he confirmed i was completely cured from fibroid, am so happy now, You do not have to suffer more just contact him for his medicine on devanshherbalheathcare@gmail.com.com he will definitely put an end to that problem of yours

    ReplyDelete
  20. I have had two myomectomy, abdominal in 05/2012 and laparoscopy in 02/2014. I have never been pregnant; not to my knowing. I’m feeling hopeless and the fibroids are growing again. Doctor said that it look like I may need another myomectomy. I know that I have a fibroid the size of a goose egg(6cm).so i was online looking for help when i saw a post about this dr buba who has helped many with root ans herbs so i wrote to him he gave me some advice and told me what to do which i did then he sent a bottle of a herbal drug to me through DHL which i used for seven days and today i am cured already all thanks to him if you
    are in my shoes or have any related sickness
    HIV AND AIDS
    HERPES
    CANCER
    STDS
    Etc
    CONTACT DR.BUBASPELLHOME@GMAIL.COM OR CALL +2348087937686 FOR URGENT HELP

    ReplyDelete
  21. I GIVE THANKS TO DR WILLIAMS FOR GIVING ME LIFE.
    He helped me with a fast cure to fibroid,and the size of it was .7cm, Then I started taking the medication for only one month, and now am completely cured from it. I was able to make it without any surgery, now I can live like every normal human and I can eat any food of my choice If you need such help, contact him via mail on drwilliams098765@gmail.com for advice,i hope this also help some one out there.

    ReplyDelete

  22. thanks to Dr ebhota, who cured me of fallopian tube blockage and fibroid. i married for over eight years wthout a child of my own. because of the problem with my fallopian tube and fibroid, until i came in contact with Dr ebhota's testimony and recommendations online, on how he has cured and healed so many people of the same illment, and i decided to contact him, and he administered his medication on me, and i became pregnant in two months. increase you want to reach him for a similar problem, you can reach him on +2347086564868 or email him,drebhota123456@gmail.com

    ReplyDelete
  23. ALL THANKS TO DR WILLIAMS WITH HIS HERB MY WIFE WAS COMPLETELY CURED FROM FIBROID.
    Is my pleasure to comment on this site and i thank the admin of this site for his/her great work so far.one of the happiest moment in life is when you see your own wife put to bed.this awesome moments makes you a man, I really don't know how to thank DR WILLIAMS for helping my wife get cured for over how many year of suffering from FIBROID. i came across DR Williams contact through a headline news on internet about how DR Williams help a woman to get cured of his fibroid and so many other with similar body problem ,i contacted him and he told me how to get his herb,few day later he sent me the herbal portion which my wife take every morning for 21 days, and his medicine was able to shrike the fibroid naturally,and now my wife is 4months old pregnant for our second child, and now she very okay without any side effects whatsoever, If you have fibroid, you can contact him on his email address drwilliams098765@gmail.com for advice and for his product

    ReplyDelete
  24. I am Shelley from Los Angeles,California, I want to testify on how i got cured from fibroid, I have suffered from fibroid since the 2011 with so mush pain,that i have to spend so mush money getting pain relief in the hospital, and I have visited several doctor ,but all to no avail, my world was gradually coming to an end because of the pin during my menstrual period until i saw a post in a health forum about a herbal Dr Williams who use herbal portion in curing people from different kind of diseases including fibroid, at first i doubted if it we be able to shrink the 9cm large fibroid in my womb, but i decided to give it a try, when i contacted this herbal doctor via his email, he prepared a herbal portion and sent it to me via courier service, when i received this herbal medicine, he gave me step by step instructions on how to apply it, when i applied it as instructed, i was completely free from fibroid just for 1 months of usage,i we recommend this to all my friend family in the world today who still suffering from fibroid you can contact him through his email on drwilliams098675@gmail.com for help.

    ReplyDelete