title: Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax.
abstract: OBJECTIVE
  To compare the distance to be traversed during needle thoracostomy decompression performed at the second intercostal space (ICS) in the midclavicular line (MCL) with the fifth ICS in the anterior axillary line (AAL).
  
  
  METHODS
  Patients were separated into body mass index (BMI) quartiles, with BMI calculated as weight in kilograms divided by height in meters squared. From each BMI quartile, 30 patients were randomly chosen for inclusion in the study on the basis of a priori power analysis (n = 120). Chest wall thickness on computed tomography at the second ICS in the MCL was compared with the fifth ICS in the AAL on both the right and left sides through all BMI quartiles.
  
  
  METHODS
  Level I trauma center.
  
  
  METHODS
  Injured patients aged 16 years or older evaluated from January 1, 2009, to January 1, 2010, undergoing computed tomography of the chest.
  
  
  RESULTS
  A total of 680 patients met the study inclusion criteria (81.5% were male and mean age was 41 years [range, 16-97 years]). Of the injuries sustained, 13.2% were penetrating, mean (SD) Injury Severity Score was 15.5 (10.3), and mean BMI was 27.9 (5.9) (range, 15.4-60.7). The mean difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL was 12.9 mm (95% CI, 11.0-14.8; P < .001) on the right and 13.4 mm (95% CI, 11.4-15.3; P < .001) on the left. There was a stepwise increase in chest wall thickness across all BMI quartiles at each location of measurement. There was a significant difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL in all quartiles on both the right and the left. The percentage of patients with chest wall thickness greater than the standard 5-cm decompression needle was 42.5% at the second ICS in the MCL and only 16.7% at the fifth ICS in the AAL.
  
  
  CONCLUSIONS
  In this computed tomography-based analysis of chest wall thickness, needle thoracostomy decompression would be expected to fail in 42.5% of cases at the second ICS in the MCL compared with 16.7% at the fifth ICS in the AAL. The chest wall thickness at the fifth ICS AAL was 1.3 cm thinner on average and may be a preferred location for needle thoracostomy decompression.
authors.affiliation: Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC+LAC Medical Center, 1200 N State St, Inpatient Tower (C)–Room C5L100, Los Angeles, CA 90033, USA. kinaba@surgery.usc.edu
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Crystal
authors.initials: C
authors.lastname: Ives
authors.forename: Kelsey
authors.initials: K
authors.lastname: McClure
authors.forename: Bernardino C
authors.initials: BC
authors.lastname: Branco
authors.forename: Marc
authors.initials: M
authors.lastname: Eckstein
authors.forename: David
authors.initials: D
authors.lastname: Shatz
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Martin
authors.forename: Sravanthi
authors.initials: S
authors.lastname: Reddy
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015992:Body Mass Index; D019299:Decompression, Surgical / Q000295:instrumentation*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009339:Needles; D011030:Pneumothorax / Q000000981:diagnostic imaging* / Q000601:surgery*; D015641:Radiography, Interventional; D012189:Retrospective Studies; D013907:Thoracostomy / Q000379:methods*; D055815:Young Adult