May 13, 2020

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

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  • Oren Krimchansky
    Posted at 05:13h, 25 May Reply

    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?

    • Salim Rezaie
      Posted at 11:09h, 25 May Reply

      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.

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