Guidelines for chest drain insertion may not prevent damage to abdominal viscera

The Nipple as a Landmark for Needle Decompression of Tension Pneumothorax in Children - A CT-Based Evaluation and Proposal of an Alternative Insertion Site

OBJECTIVE

Needle decompression of tension pneumothorax in children is a rarely encountered but potentially life-saving procedure, that is accompanied by a certain risk of injury. We evaluated the nipple as a landmark for an alternative anterior insertion site and as an aid in localizing lateral insertion sites, as well as its influence on the safety profile of the procedure.

METHODS

In thoracic computer tomography scans of children aged 0-10 years, the distance to the closest vital structure was compared between the traditional anterior insertion site (2nd intercostal space midclavicular line) and an alternative anterior insertion site (2nd intercostal space at the nipple line). Furthermore, the level of the nipple at the midaxillary line was investigated as guidance in quickly localizing the lateral insertion site and ensuring an insertion site high enough to avoid intraabdominal injury by the decompression needle. Additionally, correlation of these measures with age was investigated.

RESULTS

The distance to the closest vital structure at the 2nd intercostal space was significantly bigger at the nipple line compared to the midclavicular line (right: 2.23 ± 1.13 cm vs. 0.99 ± 0.80 cm, p < 0.0001; left: 1.92 ± 1.19 cm vs. 0.81 ± 0.70 cm, p < 0.0001). At the midaxillary line, the level of the nipple was at the 4th or 5th intercostal space in the majority of children (right: 83.8%; left: 88.1%). The mean distance from the nipple to the diaphragmatic cupola was 2.63 ± 1.85 cm on the right and 3.40 ± 1.86 cm on the left hemithorax.

CONCLUSION

When performing anterior needle decompression in children, we recommend inserting the needle at the more lateral insertion site at the 2nd intercostal space at the nipple line. At the lateral decompression sites, the nipple can be used as a marker for localizing the correct intercostal space for insertion and thereby ensuring enough caudad distance to the diaphragm to avoid abdominal injury.

Surface anatomy site for thoracostomy using the axillary hairline

Objective

Procedural complication rates associated with tube thoracostomy for pleural decompression is estimated to be between 2 and 25%, with incorrect insertion site being a common problem. We hypothesised that the inferior-most hair follicle in the axillary region would provide an accurate biometric marker to identify the fourth to sixth intercostal space.

Methods

A prospective cohort of patients requiring computed tomography scan of the chest was recruited from February 2015 to March 2016 at The Alfred Hospital. The inferior-most hair follicle on the patient’s axillary region was tagged with a paperclip, and a radiologist reported this location with reference to the corresponding intercostal spaces.

Results

Of the 254 enrolled patients, a total of 310 paperclip positions over intercostal spaces were analysed. There were 101 (32.5%) paperclips positioned in the fourth and fifth intercostal spaces with the remainder at the second or third intercostal spaces, and no paperclips placed at the sixth intercostal space or lower.

Conclusions

This study demonstrated that the inferior-most hair follicle in the axilla corresponded to an area between the second and fifth intercostal spaces. Recognition of this surface anatomy has the potential to eliminate iatrogenic injuries to the diaphragm and sub-diaphragmatic organs, but should not be used as the sole marker due to potential risks from high placement of pleural drains.

ThoraSite: A device to improve accuracy of lateral decompression needle and chest tube placement

BACKGROUND

Multiple reports have detailed an unacceptably high error rate in the siting of decompression needles and tubes and describe associated iatrogenic injuries. The objective of the current study was to measure the accuracy of the novel ThoraSite template for identifying an acceptable intercostal space (ICS) for lateral needle or tube thoracostomy.

METHODS

Two trained operators used the ThoraSite to place radiopaque needles in the left and right lateral chests of 12 cadavers. An independent radiologist reviewed fluoroscopy images to determine the primary outcome: the ICS in which each needle was placed. Secondary outcomes were ICS's palpable through ThoraSite's Safe Zone; needle placement relative to the anterior axillary line (AAL) and midaxillary line (MAL); and percent correct placement (defined as the third, fourth, or fifth ICS from 1 cm anterior to the AAL to 1 cm posterior to the MAL).

RESULTS

The six female and six male cadavers spanned 4 ft and 11 inches (150 cm) to 6 ft and 7 inches (201 cm), 80 lb (36 kg) to 350 lb (159 kg), and 16 kg/m to 42 kg/m body mass index. All 24 needles were placed in either the third (4 [17%] of 24 needles), fourth (10 [42%] of 24 needles), or fifth ICS (10 [42%] of 24 needles). In 10 (42%) of 24 assessments, two ICSs were palpable in ThoraSite's Safe Zone. All palpable ICSs were either the third (8 [24%] of 34), fourth (15 [44%] of 34); or fifth ICS (11 [32%] of 34). Twenty-three (96%) of 24 needles were inserted from 1 cm anterior to the AAL to 1 cm posterior to the MAL. Twenty-three (96%) of 24 needle placements were correct.

CONCLUSION

ThoraSite use was associated with needle placement in the third, fourth, or fifth ICS in an area roughly spanning the AAL to MAL in anatomically diverse cadavers. By facilitating appropriate needle/tube placement, ThoraSite use may decrease iatrogenic injuries. Future study involving representative users may be useful to further evaluate ThoraSite accuracy.

LEVEL OF EVIDENCE

Therapeutic and care management, level IV.

Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP)

Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the ‘safe zone’ of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation.

Finding the fifth intercostal space for chest drain insertion: guidelines and ultrasound

OBJECTIVES

International guidelines exist for chest drain insertion and recommend identifying the fifth intercostal space or above, around the midaxillary line. In a recent study, applying these guidelines in cadavers risked insertion in the 6th intercostal space or below in 80% of cases. However, there are limitations of cadaveric studies and this investigation uses ultrasound to determine the intercostal space identified when applying these guidelines in healthy adult volunteers.

METHODS

On each side of the chest wall in 31 volunteers, the position for drain insertion was identified using the European Trauma Course method, Advanced Trauma Life Support (ATLS) method, British Thoracic Society's 'safe triangle' and the 'traditional' method of palpation. Ultrasound imaging was used to determine the relationship of the skin marks with the underlying intercostal spaces.

RESULTS

Five methods were assessed on 60 sides. In contrast to the cadaveric study, 94% of skin marks lay over a safe intercostal space. However, the range of intercostal spaces found spanned the second to the seventh space. In 44% of women, the inferior boundary of the 'safe triangle' and the ATLS guidelines located the sixth intercostal space or below.

CONCLUSIONS

Current guidelines often identify a safe site for chest drain insertion, although the same site is not reproducibly found. In addition, women appear to be at risk of subdiaphragmatic drain insertion when the nipple is used to identify the fifth intercostal space. Real-time ultrasonography can be used to confirm the intercostal space during this procedure, although a safe guideline is still needed for circumstances in which ultrasound is not possible.