REBEL Core Cast 33.0 – Needle Decompression

Take Home Points

  • Forget the “traditional” needle decompression landmark
  • Decompress at 4th or 5th intercostal space in the anterior axillary line

REBEL Core Cast 32.0 – Needle Decompression


  • Tension pneumothorax is a clinical diagnosis
  • Expect the pathology in a patient with chest injury, hypotension, unilateral breath sounds, tracheal deviation, hypotension and potentially hypoxia
  • Physical exam, however, is unreliable 

2015 meta-analysis archives of surgery

  • <66% of patients had diminished breath sounds on the same side as lung collapse
  • 10% of patients had diminished breath sounds on the opposite side of lung collapse
  • Classic findings, as usual, are actually uncommon
    • Tracheal deviation and hypotension occurred in less than 1 in 5 patients
    • Hypoxia occurred in less than 1 in 10 patients
    • JVD occurred in less than 1 in 20 patients

Ultrasound (REBEL EM Link)

  • Lung sliding is absent in collapsed lung
  • M mode findings
    • Seashore appearance in normal lung – subcutaneous tissue resembles the sea and normal lung resembles the sand
    • In pneumothorax has barcode appearance, due to absence of lung movement

Literature Review 2010 Academic Emergency Medicine 

  • CXR v. US
  • US sensitivity 86-90% & specificity of 97-100%

Treatment: Needle decompression

  • Traditional Approach
    • 2nd intercostal space in the midclavicular line
    • Difficulty finding the correct anatomical site, often times going too medially 
    • 14g angiocath (with 5cm length) will fail to reach the chest cavity in more than 50% of cases
  • Modern Approach
    • 4th or 5th intercostal space in the anterior axillary line
    • Chest wall is thinner making it easier to reach chest cavity
    • Less vital structures that could be injured
    • Easier to identify correct anatomical landmarks

Needle Catheter Dislodgement & Dysfunction

  • Often times decompression done in the field and with repeated moves needle catheter can become dislodged
  • Angiocath is also prone to kinking, plastic catheter becomes softer at body temperature and can kink when needle removed.
  • Journal of Trauma and Acute Care surgery 2012 showed  needle decompression failed 20% of the time due to kinking and dislodgement

Military Guidelines 2018 

  • Recommend needle decompression with 10g, 8cm angiocath angled perpendicular to the skin
  • Hubbing catheter to the skin, and holding the entire needle/catheter unit in place for 5-10 seconds to improve decompression.

Finger Thoracostomy

  • In crashing tension pneumothorax patient the most important thing is getting access to the chest cavity and guaranteeing decompression of tension pneumothorax
  • May have less cognitive load burden secondary to just having to use a knife and finger
  • Additionally in these cases will need to follow up with a chest tube so easy enough to finger decompress than follow it up with a chest tube

Take-Home Points

  • Forget the “traditional” needle decompression landmark
  • Decompress at 4th or 5th intercostal space in the anterior axillary line

More on the Topic

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 33.0 – Needle Decompression", REBEL EM blog, May 13, 2020. Available at:
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author

Latest posts by Anand Swaminathan (see all)

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3 thoughts on “REBEL Core Cast 33.0 – Needle Decompression”

  1. Great stuff there!
    Waht do you think about mini-thoracotomy without a tube but with a one directional valve for out of the hospital emergency?

    • Hello Oren,
      My worry is in a resource/man/woman limited environment with addition of a stressful situation, does adding more steps and cognitive load potentially lead to more complications. Not against the idea, just playing devils advocate.

  2. Hi, thanks for this interesting podcast! Looking at recent data, with a sufficiently long needle >7cm, it seems like both approaches (anterior vs lateral) are pretty much similar in term of potential success rate. Pieces of evidence regarding potential adverse event rate are of low quality and usually were calculated radiologically assuming an adequate landmarking, but it seems like there might be an increased risk of heart puncture for the lateral approach (left side) with the recommended needle length (especially with a hub to the skin approach). Knowing this, do you think it is still appropriate to forget about anterior placement? Besides a potential easier landmarking which may potentially be fixed by adequate training, I’m not sure I see a crystal clear benefit for the prioritisation of the lateral approach. I agree that finger thoracostomy, despite not being very well studied in my setting (prehospital) is probably the best approach. I’m very curious to hear about your input! Here is a new publication on the subject:


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