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Exsufflation: 5 cm antérieur survie = 9 latéral

Needle Thoracostomy: Does Changing Needle Length and Location Change Patient Outcome?
Un travail aux résultats qui interpellent. Il compare 2 pratiques (exsufflation antérieure avec un KT de 5 cm et exsufflation latérale avec un KT de 9 cm) et qui ne met pas en évidence d'avantage à l'emploi de cathéter d'exsufflation de grande longueur en terme de survie. Pour rappel l'exsufflation au doigt doit rester la référence (Lire la fiche memento)


Needle thoracostomy (NT) is a common prehospital intervention for patients in extremis or cardiac arrest due to trauma. The purpose of this study is to compare outcomes, efficacy, and complications after a change in policy related to NT in a four-county Emergency Medical Services (EMS) system with a catchment area of greater than 1.6 million people.


This is a before and after observational study of all patients who had NT performed in the Central California (USA) EMS system. The before, anterior midclavicular line (MCL) group consisted of all patients who underwent NT from May 7, 2007 through February 28, 2013. The after, midaxillary line (MAL) axillary group consisted of all patients who underwent NT from March 1, 2013 through January 30, 2016, after policy revisions changed the timing, needle size, and placement location for NT. All prehospital and hospital records where NT was performed were queried for demographics, mechanism of injury, initial status and post-NT clinical change, reported complications, and final outcome. The trauma registry was accessed to obtain Injury Severity Scores (ISS). Information was manually abstracted by study investigators and examined utilizing univariate and multivariate analyses.


Three-hundred and five trauma patients treated with NT were included in this study, of which, 169 patients (the MCL group) were treated with a 14-gauge intravenous (IV) catheter at least 5.0-cm long at the second intercostal space (ICS), MCL after being placed in the ambulance; and 136 patients (the MAL group) were treated with a 10-gauge IV catheter at least 9.5-cm long at the fifth ICS, MAL on scene. The mean ISS was lower in the MAL cohort (64.5 versus 69.2; P=.007). The mortality rate was 79% in both groups.


The multivariate model with regard to survival supported that a lower ISS (P<.001) and reported clinical change after NT (P=.003) were significant indicators of survival. No complications from NT were reported.


Changing the timing, length of needle, and location of placement did not change mortality in patients requiring NT. Needle thoracostomy was used more frequently after the change in policy, and the MAL cohort was less injured. No increase in reported complications was noted.


A lire

Prolonged Field Care of a Casualty With Penetrating Chest Trauma Case Report

Barnhart G. et Al. J Spec Oper Med. Winter 2016;16(4):99-101


As Special Operations mission sets shift to regions with less coalition medical infrastructure, the need for quality long-term field care has increased. More and more, Special Operations Medics will be expected to maintain casualties in the field well past the "golden hour" with limited resources and other tactical limitations. This case report describes an extended-care scenario (>12 hours) of a casualty with a chest wound, from point of injury to eventual casualty evacuation and hand off at a Role II facility. This case demonstrates the importance of long-term tactical medical considerations and the effectiveness of minimal fluid resuscitation in treating penetrating thoracic trauma.

Histoire à lire

A Case of Prehospital Traumatic Arrest in a US Special Operations Soldier: Care From Point of Injury to Full Recovery

During an assault on an extremely remote target, a US Special Operations Soldier sustained multiple gunshot and fragmentation wounds to the thorax, resulting in a traumatic arrest and subsequent survival. His care, including care under fire, tactical field care, tactical evacuation care, and Role III, IV, and V care, is presented. The case is used to illustrate the complex dynamics of Special Operations care on the modern battlefield and the exceptional outcomes possible when evidence-based medicine is taken to the warfighter with effective,


Exsufflation axillaire: Plus sûre

Relative device stability of anterior versus axillary needle decompression for tension pneumothorax during casualty movement: Preliminary analysis of a human cadaver model



Tension pneumothorax (tPTX) remains a significant cause of potentially preventable death in military and civilian settings. The current prehospital standard of care for tPTX is immediate decompression with a 14-gauge 8-cm angiocatheter; however, failure rates may be as high as 17% to 60%. Alternative devices, such as 10-gauge angiocatheter, modified Veress needle, and laparoscopic trocar, have shown to be potentially more effective in animal models; however, little is known about the relative insertional safety or mechanical stability during casualty movement.


Seven soft-embalmed cadavers were intubated and mechanically ventilated. Chest wall thickness was measured at the second intercostal space at the midclavicular line (2MCL) and the fifth intercostal space along the anterior axillary line (5AAL). CO2 insufflation created a PTX, and needle decompression was then performed with a randomized device. Insertional depth was measured between hub and skin before and after simulated casualty transport. Thoracoscopy was used to evaluate for intrapleural placement and/or injury during insertion and after movement. Cadaver demographics, device displacement, device dislodgment, and injuries were recorded. Three decompressions were performed at each site (2MCL/5AAL), totaling 12 events per cadaver.


Eighty-four decompressions were performed. Average cadaver age was 59 years, and body mass index was 24 kg/m. The CWT varied between cadavers because of subcutaneous emphysema, but the average was 39 mm at the 2MCL and 31 mm at the 5AAL. Following movement, the 2MCL site was more likely to become dislodged than the 5AAL (67% vs. 17%, p = 0.001). Median displacement also differed between 2MCL and 5AAL (23 vs. 2 mm, p = 0.001). No significant differences were noted in dislodgement or displacement between devices. Five minor lung injuries were noted at the 5AAL position.



Preliminary results from this human cadaver study suggest the 5AAL position is a more stable and reliable location for thoracic decompression of tPTX during combat casualty transport.

| Tags : pneumothorax


3 côtés: Non occlusif ? Pas tous égaux

Do vented chest seals differ in efficacy? An experimental evaluation using a swine hemopneumothorax model

Kheirabadi BS et Al. J Trauma Acute Care Surg. 2017 Apr 18. doi: 10.1097/TA.0000000000001501.


Un travail très pratique qui fait le point sur la performance des pansements 3 côtés non occlusifs. Plusieurs sont disponibles sur le marché. Mais qu'en est il des divers dispositifs proposés sur le marché. On dispose déjà de données concernant les propriétés "adhésives" de ces dispositifs (1). Avec ce travail, on a en plus une idée sur la capacité de ces pansements à permettre l'écoulement de saignement intra-thoraciques. L'historique valve d'asherman doit être considérée comme obsolète.



Hemopneumothorax (HPTX) is the second leading cause of potentially preventable death among combat casualties. We investigated the ability of five FDA-approved non-occlusive chest seals (CSs) to seal a bleeding chest wound and prevent tension HPTX in a swine model.


Following instrumentation, an open chest wound was created in the left thorax of spontaneously air-breathing anesthetized pigs (n=26, 43 Kg). Autologous fresh blood (226 mL) was then infused into the pleural cavity to produce HPTX. The chest wounds were then sealed with CSs. The sealant strength and venting function of CSs were challenged by infusion of 50 mL more blood directly into the chest wound and incremental air injections into the pleural cavity. Tension HPTX was defined as intrapleural (IP) pressure ≥ +1 mmHg and >20% deviation in physiological measurements.


An open chest wound with HPTX raised IP pressure (~ -0.7 mmHg) and caused labored breathing and reductions in PaO2 and SvO2 (P<0.01). Sealing the wounds with the CSs restored IP pressure, and improved breathing and oxygenation. Subsequent blood infusion into the wound and IP air injections produced CS-dependent responses.

3 Cotés efficacité.jpg


CSs with one-way valves (Bolin and SAM) did not evacuate the blood efficiently; pooled blood either detached the CSs from skin and leaked out (75%), or clotted and clogged the valve and led to tension HPTX (25%). Conversely, CSs with laminar venting channels allowed escape of blood and air from the pleural cavity and maintained IP pressure and oxygenation near normal levels. Success rates were 100% for Sentinel and Russell (6/6); 67% for HyFin (4/6); 25% for SAM (1/4); and 0% for Bolin (0/4) CSs (p=0.002).


The sealant and valve function of vented CS differed widely in the presence of bleeding chest wounds. Medics should be equipped with more effective CSs for treating HPTX in the field.

| Tags : pneumothorax


Décompression pleurale: Dur, dur...

Failure rate of prehospital chest decompression after severe thoracic trauma.

Kaserer A. et Al Am J Emerg Med. 2016 Nov 30. pii: S0735-6757(16)30892-0


Une publication qui émane de nos collègues suisses et qui interpelle quelque peu. La décompression thoracique apparat être un geste dont la maîtrise est largement insuffisante y compris quand elle est réalisée au sein d'un système mature. Une raison de plus pour s'intéresser à la maîtrise effective des gestes censés participer à la mise en condition de survie des blessés. On rappelle l'intérêt de la thoracostomie au doigt (1), doigt dont la longueur est en général suffisante pour entrer dans un thorax.



Chest decompression can be performed by different techniques, like needle thoracocentesis (NT), lateral thoracostomy (LT), or tube thoracostomy (TT). The aim of this study was to report the incidence of prehospital chest decompression and to analyse the effectiveness of these techniques.


In this retrospective case series study, all medical records of adult trauma patients undergoing prehospital chest decompression and admitted to the resuscitation area of a level-1 trauma center between 2009 and 2015 were reviewed and analysed. Only descriptive statistics were applied.


In a 6-year period 24 of 2261 (1.1%) trauma patients had prehospital chest decompression. Seventeen patients had NT, six patients TT, one patient NT as well as TT, and no patients had LT. Prehospital successful release of a tension pneumothorax was reported by the paramedics in 83% (5/6) with TT, whereas NT was effective in 18% only (3/17). In five CT scans all thoracocentesis needles were either removed or extrapleural, one patient had a tension pneumothorax, and two patients had no pneumothorax. No NT or TT related complications were reported during hospitalization.



Prehospital NT or TT is infrequently attempted in trauma patients. Especially NT is associated with a high failure rate of more than 80%, potentially due to an inadequate ratio between chest wall thickness and catheter length as previously published as well as a possible different pathophysiological cause of respiratory distress. Therefore, TT may be considered already in the prehospital setting to retain sufficient pleural decompression upon admission.

| Tags : pneumothorax


Adhérence des pansements 3 côtés: Pas tous équivalents

Adherence Evaluation of Vented Chest Seals in a Swine Skin model

Arnaud F. et Al. Injury doi:10.1016/j.injury.2016.05.041


L'adhérence cutanée est une caractéristique importante des pansements 3 côtés industriels. A l'évidence il existe des différences. C'est ce que démontre ce travail particulièrement intéressant car il napporte également quelques informations sur les effets de la température de stockage sur ces dispositifs. Une remarque: la peau est celle de cochons (lire aussi ce travail non publié)



Perforation of the chest (open pneumothorax) with and without lung injury can cause air accumulation in the chest, positive intrapleural pressure and lead to tension pneumothorax if untreated. The performance of chest seals to prevent tension physiology depends partially on their ability to adhere to the skin and seal the chest wound. Novel non-occlusive vented chest seals were assessed for their adhesiveness on skin of live swine under normal and extreme environmental conditions to simulate austere battlefield conditions.


Chest seals were applied on the back of the swine on skin that was soiled by various environmental contaminants to represent battlefield situations. A peeling (horizontal rim peeling) and detachment and breaching (vertical pulling) techniques were used to quantify the adhesive performance of vented chest seals. Among eight initially selected vented seals, five (Bolin, Russell, Fast breathe, Hyfin and SAM) were further down-selected based on their superior adherence scores at ambient temperatures. The adherence of these seals was then assessed after approximately 17 h storage at extreme cold (-19.5 °C) and hot (71.5 °C) temperatures.


Adherence scores for peeling (above 90%) and detachment scores (less than 25%) were comparable for four vented chest seals when tested at ambient temperature, except for the Bolin seal which had higher breaching. Under extreme storage temperatures, adherence peeling scores were comparable to those at ambient temperatures for four chest seals.


Scores were significantly lower for the Bolin seal at extreme temperatures. This seal also had the highest detachment and breaching scores. In contrast, the Russell, Fast breathe, Hyfin and SAM seals showed similar ability to stay air tight without breaching after hot storage.


No significant difference was found in skin adherence of the five vented chest seals at ambient temperature and the four seals (Russell, Fast breathe, Hyfin and SAM) maintained superior adherence even after exposure to extreme temperatures compared to the Bolin. To select the most effective product from the 5 selected vented chest seals, further functional evaluation of the valve of these chest seals on a chest wound with the potential for tension in the pneumothorax or hemopneumothorax is warranted.



la voie axillaire +++

Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy

Laan DV et Al. Injury, Int. J. Care Injured 47 (2016) 797–804


Une publication, une de plus, qui met en avant l'abord axillaire pour la décompression thoracique et qui insiste sur le peu de preuve de l'inocuité des cathéters de 8 cm. On rappelle que la thoracostomie au doigt reste la référence.



Current Advanced Trauma Life Support guidelines recommend decompression for thoracic tension physiology using a 5-cm angiocatheter at the second intercostal space (ICS) on the midclavicular line (MCL). High failure rates occur. Through systematic review and meta-analysis, we aimed to determine the chest wall thickness (CWT) of the 2nd ICS-MCL, the 4th/5th ICS at the anterior axillary line (AAL), the 4th/5th ICS mid axillary line (MAL) and needle thoracostomy failure rates using the currently recommended 5-cm angiocatheter.


A comprehensive search of several databases from their inception to July 24, 2014 was conducted. The search was limited to the English language, and all study populations were included. Studies were appraised by two independent reviewers according to a priori defined PRISMA inclusion and exclusion criteria. Continuous outcomes (CWT) were evaluated using weighted mean difference and binary outcomes (failure with 5-cm needle) were assessed using incidence rate. Outcomes were pooled using the random-effects model.


The search resulted in 34,652 studies of which 15 were included for CWT analysis, 13 for NT effectiveness. Mean CWT was 42.79 mm (95% CI, 38.78–46.81) at 2nd ICS-MCL, 39.85 mm (95% CI, 28.70–51.00) at MAL, and 34.33 mm (95% CI, 28.20–40.47) at AAL (P = .08). Mean failure rate was 38% (95% CI, 24–54) at 2nd ICS-MCL, 31% (95% CI, 10–64) at MAL, and 13% (95% CI, 8–22) at AAL (P = .01).


Evidence from observational studies suggests that the 4th/5th ICS-AAL has the lowest predicted failure rate of needle decompression in multiple populations.


Exsufflation: Cela se complique !

Complications of needle thoracostomy: A comprehensive clinical review

Wernjck B et Al. Int J Crit Illn Inj Sci. 2015 Jul-Sep; 5(3): 160–169


Comme toujours, après une phase d'engouement vient le temps de la réflexion. L'exsufflation à l'aiguille n'est pas d'une indication si fréquente et en plus expose à certaines complications. A lire avant de se lancer dans l'utilisation d'aiguille de tout genre.


Needle thoracostomy (NT) is a valuable adjunct in the management of tension pneumothorax (tPTX), a life-threatening condition encountered mainly in trauma and critical care environments. Most commonly, needle thoracostomies are used in the prehospital setting and during acute trauma resuscitation to temporize the affected individuals prior to the placement of definitive tube thoracostomy (TT). Because it is both an invasive and emergent maneuver, NT can be associated with a number of potential complications, some of which may be life-threatening. Due to relatively common use of this procedure, it is important that healthcare providers are familiar, and ready to deal with, potential complications of NT.

| Tags : pneumothorax


Drainer un thorax sans drain

Improvised Chest Tube Drain for Decompression of an Acute Tension Pneumothorax

Vinson ED Mil Med. 2004 May;169(5):403-5.


Décomprimer un thorax est indispensable en cas de pneumothorax suffocant.  Si la décompression à l'aiguille est souvent présentée comme la technique de référence, encore faut il que sa réalisation soit faite par voie latérale avec un cathéter de calibre et longueur suffisant. Néanmoins cette technique est sujette à échec. La thoracostomie au doigt est la méthode la plus efficiente et la moins dangereuse. La justification de la pose d'un drain thoracique est moins claire: durée de transport conséquent, reconstitution du pneumothorax. Encore faut il avoir un drain.Si le cathéter du minitrach percut 2 peut être utilisé, c'est aussi le cas d'une ligne et d'une poche de perfusion qui semblent être une alternative à ne pas méconnaitre.


A case of a woman presenting with an acute tension pneumothorax during a Navy humanitarian mission in East Timor is presented. The patient was treated at a local rural clinic run by our medical team. Prompt insertion of a chest tube saved the woman’s life; however, there were no chest tube drains available. A field chest tube drain constructed out of an IV bag, a sterile water bottle, and tubing provided an adequate underwater seal and drain. Because of the remote location and limited resources, standard prehospital chest tube management had to be modified. A brief review of simple and tension pneumothoraces and management along with a description of the field chest tube drain is presented

drainage thorax

"The equipment needed includes a 24-French chest tube, a 100-mL NS IV bag, a 1,000-mL plastic sterile saline bottle, and two standard primary IV tube sets. The sterile water bottle is prepared by first emptying the contents. Next, two holes should be cut large enough to fit the surgical tubing, one in the cap, and one in the top of the bottle. The IV bag and primary IV tubing should be attached and the tube should be cut between the filter and reservoir. This end is left open for a vent. The other outlet port should be cut open to allow one end of a surgical tube to be inserted. The chest tube is then attached to the plastic spike of the other IV tubing. The other end of the tube is placed into the sterile water bottle through the hole in the cap. The surgical tube from the IV bag outlet port should be attached to the sterile water bottle through the hole in the side. The surgical tubing from the sterile water bag needs to be long enough to reach the top of the IV bag. To operate the system, the IV bag should be inverted to keep the underwater seal to the sterile water bottle. This allows the long tube to stay underwater while the short tube vents air out of the bag. To dispose of any accumulated fluid, the chest tube is first clamped near the patient. The water bottle can then be removed and emptied while the cap remains attached to the chest tube. It is then a simple matter to reattach the bottle and unclamp the chest tube"

| Tags : drainage thorax


Thoracostomie: ni en antérieur ou postérieur mais par voie latérale

Evaluation of the Risk of Intercostal Artery Laceration During Thoracentesis in Elderly Patients by Using 3D-CT Angiography

Yoneyama H. et Al Inter Med 49: 289-292, 2010


Les artères intercostales ne cheminent pas toujours au rebord inférieur de de la côte supérieure. Il existe de plus des rameaux latéraux plutôt postérieurs. Donc il faut aborder le thorax par voie latérale. Une approche latérale au niveau des 4/5èmes espaces intercostaux sur la lgne axillaire moyennne est sécuritaire.  



Our study was undertaken to determine the location of the tortuous intercostal artery in elderly patients by using 3D-CT angiography in order to prevent laceration during thoracentesis.


We evaluated the data of 3D-CT angiography of the intercostal artery in consecutive patients who had undergone contrast chest CT scan in our hospital from December 2007 to April 2008. We considered the “percent safe space” (the shortest lower rib-to-intercostal artery distance/the upper rib-to-lower rib distance) to be an index of safety that can be used to prevent laceration of the intercostal artery during thoracentesis. We measured this index at 3 points: the total site (5-10 cm lateral to the spine), the lateral site (9-10 cm lateral to the spine), and the medial site (5-6 cm lateral to the spine).


We evaluated 33 cases (25 males and 8 females; mean age, 74.2 years). The mean percent safe space at the total site was 58.6%. The percent safe space at the total site tended to decrease with advancing age, but the correlation was low (p=0.0378, r=-0.3631). The percent safe space at the lateral site (mean, 79.8%) was significantly higher than that at the medial site (61.2%, p<0.0001).


We showed that the intercostal artery is tortuous and does not always lie along the inferior edge of the rib and that the percent safe space at the lateral site is significantly higher than that at the medial site in elderly patients

| Tags : exsufflation


Décompression à l'aiguille: Pas fiable

Does needle thoracostomy provide adequate and effective decompression of tension pneumothorax?

Martin M et Al. J Trauma Acute Care Surg. 2012;73: 1412-1417


La décompression thoracique est une des mesures qui vise à réduire le nombre de morts évitables. Il s'agit d'une procédure mise en oeuvre peu fréquemment. L'exsufflation à l'aiguille est la méthode enseignée. Il existe beaucoup de débats concernant le lieu de ponction (plutôt par voie axillaire et non par voie antérieure), la longueur du cathéter (certains proposent 8 cm au risque de ponction parenchymateuse et des gros vaisseaux), le diamètre. Le travail proposé est très intéressant car il exprime toute les réserves qui doivent encadrer ce geste qui ne semble pas aussi efficace que cela car outre les problèmes mécanique il apparaît bien qu'un cathéter de 14G risque d'être insuffisant. On rappelle quand même que la thoracostomie au doigt est toujours possible et que votre doigt a de fortes chances de mesurer 8 cm donc de pouvoir pénétrer dans un thorax après création d'un stomie intercostale à la pince de monro-kelly.



Tension pneumothorax (tPTX) is a common and potentially fatal event after thoracic trauma. Needle decompression is the currently accepted first-line intervention but has not been well validated. The purpose of this study was to evaluate the effectiveness of a properly placed and patent needle thoracostomy (NT) compared with standard tube thoracostomy (TT) in a swine model of tPTX.


Six adult swine underwent instrumentation and creation of tPTX using thoracic CO2 insufflation via a balloon trocar. A continued 1 L/min insufflation was maintained to simulate an ongoing air leak. The efficacy and failure rate of NT (14 gauge) compared with TT (34F) was assessed in two separate arms: (1) tPTX with hemodynamic compromise and (2) tPTX until pulseless electrical activity (PEA) obtained. Hemodynamics was assessed at 1 and 5 minutes after each intervention.


A reliable and highly reproducible tPTX was created in all animals with a mean insufflation volume of 2441 mL. tPTX resulted in the systolic blood pressure declining 54% from baseline (128Y58 mm Hg), cardiac output declining by 77% (7Y1.6 L/min), and equalization of central venous pressure and wedge pressures. In the first arm, there were 19 tPTX events treated with NT placement. All NTs were patent on initial placement, but 5 (26%) demonstrated mechanical failure (due to kinking, obstruction, or dislodgment) within 5 minutes of placement, all associated with hemodynamic decline. Among the 14 NTs that remained patent at 5 minutes, 6 (43%) failed to relieve tension physiology for an overall failure rate of 58%. Decompression with TTwas successful in relieving tPTX in 100%. In the second arm, there were 21 tPTX with PEA events treated initially with either NT (n = 14) or TT (n = 7). The NT failed to restore perfusion in nine events (64%), whereas TT was successful in 100% of events as a primary intervention and restored perfusion as a rescue intervention in eight of the nine NT failures (88%).

CONCLUSION: Thoracic insufflation produced a reliable and easily controlled model of tPTX. NT was associated with high failure rates for relief of tension physiology and for treatment of tPTX-induced PEA and was due to both mechanical failure and inadequate tPTX evacuation. This performance data should be considered in future NT guideline development and equipment design


Exsufflation: Ø plutôt que longueur

Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience

Chen J et Al. Can J Surg 2015;58(3):S118-S124


Il existe un grand débat sur la nature du cathéter à utiliser pour décomprimer un thorx sous pression. Ce travail est intéressant car, alors qu'il existe une forte pression pour recourir à des cathéters de 8cm, il rapporte une expérience de terrain conséquente où le recours à un angiocath n'a pas été lié à un taux d'échec rédhibitoire puisque 8 fois sur 1 une amélioration clinique est notée. Pour ces auteurs le débat porte plus sur le diamètre du cathéter que sa longueur. Ce document insiste également sur la disparition unilatérale du murmure vésiculaire comme repère du côté à ponctionner.


Contexte :

La thoracotomie à l’aiguille (TA) pour le pneumothorax sous tension sur les lieux mêmes du traumatisme peut sauver des vies. Des données récentes ont mis en doute l’efficacité des dispositifs de TA classiques. C’est pourquoi le corps médical de l’armée israélienne (CMAI) a récemment proposé un cathéter plus long, plus large et plus résistant pour décomprimer rapidement le pneumothorax. Le présent article résume l’expérience du CMAI en matière de décompression des pneumothorax au moyen de la TA.

Méthodes :

Nous avons passé en revue le registre des traumatismes de l’armée israé- lienne entre janvier 1997 et octobre 2012 pour relever tous les cas où une TA a été tentée.

Résultats :

Durant la période de l’étude 111 patients en tout ont subi une décompression à l’aide d’une TA. La plupart des cas (54 %) résultaient de blessures par balles; les accidents de la route venaient au second rang (16 %). La plupart (79 %) des TA ont été effectuées sur les lieux, tandis que les autres ont été effectuées durant l’évacuation par ambulance ou par hélicoptère (13 % et 4 %, respectivement). L’atténuation des bruits respiratoires du côté affecté était l’une des indications cliniques les plus fréquentes de la TA, enregistrée dans 28 % des cas. L’atténuation des bruits respiratoires était plus fréquente chez les patients qui ont survécu (37 % c. 19 %, p < 0,001). Un drain thoracique a été installé sur le terrain chez 35 patients (32 %), à chaque fois après une TA.

Conclusion :

La TA standard s’accompagne d’un taux d’échec élevé sur le champ de bataille. Une autre mesure de décompression, comme le cathéter Vygon, semble être une solution de rechange envisageable à la TA classique.

| Tags : exsufflation


Exsuffler: Aiguille de 6,44cm ?

Sufficient catheter length for pneumothorax needle decompression: a meta-analysis

Clemency BM et Al. Prehosp Disaster Med. 2015 Jun;30(3):249-53


Introduction Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. The authors of this study determined minimum catheter length needed for procedural success on a percentile basis.


A meta-analysis of existing studies was conducted. A Medline search was performed using the search terms: needle decompression, needle thoracentesis, chest decompression, pneumothorax decompression, needle thoracostomy, and tension pneumothorax. Studies were included if they published a sample size, mean chest wall thickness, and a standard deviation or confidence interval. A PubMed search was performed in a similar fashion. Sample size, mean chest wall thickness, and standard deviation were found or calculated for each study. Data were combined to create a pooled dataset. Normal distribution of data was assumed. Procedural success was defined as catheter length being equal to or greater than the chest wall thickness.


The Medline and PubMed searches yielded 773 unique studies; all study abstracts were reviewed for possible inclusion. Eighteen papers were identified for full manuscript review. Thirteen studies met all inclusion criteria and were included in the analysis. Pooled sample statistics were: n=2,558; mean=4.19 cm; and SD=1.37 cm. Minimum catheter length needed for success at the 95th percentile for chest wall size was found to be 6.44 cm. Discussion A catheter of at least 6.44 cm in length would be required to ensure that 95% of the patients in this pooled sample would have penetration of the pleural space at the site of needle decompression, and therefore, a successful procedure. These findings represent Level III evidence. 

| Tags : exsufflation


Faut il drainer avant de décoller: Non ?

Air Transport of Patients with Pneumothorax: Is Tube Thoracostomy Required Before Flight ?

Braude D et Al. Air Med J. 2014 Jul-Aug;33(4):152-6

Objective: It is conventionally thought that patients with pneumothorax (PTX) require tube thoracostomy (TT) before air medical transport (AMT), especially in unpressurized rotor-wing (RW) aircraft, to prevent deterioration from expansion of the PTX or development of tension PTX. We hypothesize that patients with PTX transported without TT tolerate RW AMT without serious deterioration, as defined by hypotension, hypoxemia, respiratory distress, intubation, bag valve mask ventilation, needle thoracostomy (NT), or cardiac arrest during transport.

Methods: We conducted a retrospective review of a case-series of trauma patients transported to a single Level 1 trauma center via RW with confirmed PTX and no TT. Using standardized abstraction forms, we reviewed charts for signs of deterioration. Those patients identified as having clinical deterioration were independently reviewed for the likelihood that the clinical deterioration was a direct consequence of PTX.

Results: During the study period, 66 patients with confirmed PTX underwent RW AMT with an average altitude gain of 1890 feet, an average barometric pressure 586-600 mmHg, and average flight duration of 28 minutes. All patients received oxygen therapy; 14/66 patients (21%) were supported with positive pressure ventilation. Eleven of 66 patients (17%) had NT placed before flight and 4/66 (6%) had NT placed during flight. Four of 66 patients (6% CI0.3-11.7) may have deteriorated during AMT as a result of PTX; all were successfully managed with NT.

Conclusions: In this series, 6% of patients with PTX deteriorated as result of AMT without TT, yet all patients were managed successfully with NT. Routine placement of TT in patients with PTX before RW AMT may not be necessary. Further prospective evaluation is warranted.


Par le côté et avec du long ?

Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax

Chang SJ et Al. J Trauma Acute Care Surg. 2014;76: 1029-1034


La décompression d'un thorax sous pression doit maintenant se faire par voie latérale, la voie antérieure étant associée à un taux d'échec important notamment avec l'emploi de cathéters veineux classiques dont la longueur est rarement supérieure à 5 cm. Le recours à des cathéters de 8 cm est ainsi prôné dans la littérature anglo-saxone sur des seuls arguments  anatomiques. Le risque de ponction de structures intrathoraciques est réel et doit rendre mesuré quand au recours à de tels dispositifs. On rappelle que la thoracostomie au doigt doit être considérée comme la référence. 

BACKGROUND: Five-centimeter needles at the second intercostal space midclavicular line (2MCL) have high failure rates for decompression of tension pneumothorax. This study evaluates 8-cm needles directed at the fourth intercostal space anterior axillary line (4AAL).
METHODS: Retrospective radiographic analysis of 100 consecutive trauma patients 18 years or older from January to September 2011. Measurements of chest wall thickness (CWT) and depth to vital structure (DVS) were obtained at 2MCL and 4AAL. 4AAL measurements were taken based on two angles: closest vital structure and perpendicular to the chest wall. Primary outcome measures were radiographic decompression (RD) (defined as CWT G 80 mm) and radiographic noninjury (RNI) (DVS 9
80 mm) of 8-cm needles at 4AAL. Secondary outcome measures are effect of angle of entry on RNI at 4AAL, RD and RNI of 8-cm needles at 2MCL, and comparison of 5-cm needles with 8-cm needles at both locations.
RESULTS: Eighty-four percent of the patients were male, with mean Injury Severity Score (ISS) of 17.7 (range, 1.0Y66.0) and body mass index of 26.8 (16.5Y48.4). Mean CWT at 4AAL ranged from 37.6 mm to 39.9 mm, significantly thinner than mean CWT at 2MCL (43.3Y46.7 mm). Eight-centimeter needle RD was more than 96% at both 4AAL and 2MCL. Five-centimeter RD ranged from 66% to 81% at all sites. Mean DVS at 4AAL ranged from 91.8 mm to 128.0 mm. RNI at all sites was more than 91% except at left 4AAL, when taken to the closest vital structure (mean DVS, 91.8 mm), with 68% RNI. Perpendicular entry
increased DVS to 109.4 mm and subsequent RNI to 91%. Five-centimeter RNI at all sites was more than 99%.


CONCLUSION: CWT at 4AAL is significantly thinner than 2MCL. Based on radiographic measurements, 8-cm catheters have a higher chance of pleural decompression when compared with 5-cm catheters. Steeper angle of entry at 4AAL improves 8-cm noninjury rates to more than 91%. 


Pneumothorax: Passez par le côté

Failed needle decompression of bilateral spontaneous tension pneumothorax

Bac PT et Al. Acta Anaesthesiol Scand. 2015 Apr 21. doi: 10.1111/aas.12538. [Epub ahead of print]


Cet article a le mérite de rappeler que la détresse respiratoire est ua prmeier plan enc as de pneumothorax suffocant chez le patient non ventilé, que la voie latérale doit être privilégié et surtout que la thoracostomie simple est parfaitement efficace.


This case report presents a young male admitted with primary bilateral spontaneous tension pneumothorax and severe respiratory distress. This is an extremely rare condition. The patient was on the verge of hypoxic cardiac arrest and the attempted needle thoracocentesis was unsuccessful. Needle thoracocentesis in the midclavicular line of the second intercostal space is widely used and recommended as first-line treatment of tension pneumothorax. Reviewing the literature, the procedure is not based on solid evidence. It has high failure rates and potentially serious complications. Alternatives to this approach are perhaps more appropriate. Correctly done, needle thoracocentesis has its place in the presence of a diagnosed or suspected tension pneumothorax when no other options are available. If needle thoracocentesis is chosen, then insertion in the mid-anterior axillary line of the 3rd–5th intercostal space is an appropriate alternative site. Otherwise, lateral thoracostomy, with or without chest tube insertion, is a safe procedure with a high success rate. It should be considered as the first-line treatment of tension pneumothorax, particularly in the unstable patient


Pansements 3 côtés: C'est efficace

Vented Chest Seals for Prevention of Tension Pneumothorax in a Communicating Pneumothorax

Kotora JG et Al.  J Emerg Med. 2013 Nov;45(5):686-94.


La prise en charge d'une plaie thoracique soufflante (1est une éventualité peu fréquente qui expose d'une part au risque de détresse respiratoire aiguë et d'autre part au risque d'instabilité hémodynamique en rapport avec le caractère compressif d'un épanchement intra-thoracique gazeux ou liquidien (2) L'exsufflation et/ou la pose d'un pansement 3 côtés sont alors requis. Ce dernier peut être réalisé simplement ou par l'emploi de dispositifs commerciaux prêts à l'emploi. Le travail présenté exprime l'efficacité des pansements "3 côtés" de dernières générations aussi bien en matière d'adhérence cutanée que d'efficacité d'évacuation de l'air et secrétions intra-thoraciques. Ils jouent donc ainsi parfaitement le rôle pour lesquels ils ont été conçus (3).




Tension pneumothorax accounts for 3%–4% of combat casualties and 10% of civilian chest trauma. Air entering a wound via a communicating pneumothorax rather than by the trachea can result in respiratory arrest and death. In such cases, the Committee on Tactical Combat Casualty Care advocates the use of unvented chest seals to prevent respiratory compromise.

OBJECTIVE: A comparison of three commercially available vented chest seals was undertaken to evaluate the efficacy of tension pneumothorax prevention after seal application.


A surgical thoracostomy was created and sealed by placing a shortened 10-mL syringe barrel (with plunger in place) into the wound. Tension pneumothorax was achieved via air introduction through a Cordis to a maximum volume of 50 mL/kg. A 20% drop in mean arterial pressure or a 20% increase in heart rate confirmed hemodynamic compromise. After evacuation, one of three vented chest seals (HyFin ®, n = 8; Sentinel ®, n = 8, SAM ®, n = 8) was applied. Air was injected to a maximum of 50 mL/kg twice, followed by a 10% autologous blood infusion, and finally, a third 50 mL/kg air bolus. Survivors completed all three interventions, and a 15-min recovery period.



The introduction of 29.0 (±11.5) mL/kg of air resulted in tension physiology. All three seals effectively evacuated air and blood. Hemodynamic compromise failed to develop with a chest seal in place.



HyFin ®, SAM ®, and Sentinel ® vented chest seals are equally effective in evacuating blood and air in a communicating pneumothorax model. All three prevented tension pneumothorax formation after penetrating thoracic trauma


Pneumo suffocant: Oui




Clic sur l'image pour accéder au document

Pneumothorax compressif, sous tension, tamponnade gazeuse. Autant de termes utilisés pour cette situation clinique à laquelle est souvent associé l'existence d'une hypotension artérielle, en fait surtout présente chez les patients ventilés. La détresse respiratoire est souvent au premier plan che le blessé non ventilé et le terme de pneumothorax suffocant adapté. Le document proposé est un peu ancien mais apporte une vision relativement didactique de la problématique séméiologique et physiopathologique.

| Tags : pneumothorax


Un trocard de coelio ?

Standard laparoscopic trocars for the treatment of tension pneumothorax: A superior alternative to needle decompression

Quinton H. et Al. J Trauma Acute Care Surg. 2014;77: 170-175.


Le recours à un cathéter d'au moins 8 cm est prôné par certains du fait de l'épaisseur de la paroi thoracique. L'inconvénient de cette longueur est le risque non négligeable de ponction parenchymateuse surtout lors de l'emploi de la voie antérieure.


La voie latérale exposerait maoins à ce risque. Une alternative bien moins dangereuse et toute aussi efficace est la thoracostomie au doigt. Et pourquoi pas un trocard de coelio ?


BACKGROUND: Needle thoracostomy (NT) is a commonly taught intervention for tension pneumothorax (tPTX) but has a high failure rate. We hypothesize that standard 5-mm laparoscopic trocars may be a safe and more effective alternative.

Thirty episodes of tPTX and 27 episodes of tension-induced pulseless electrical activity (PEA) were induced in five adult swine using thoracic CO2 insufflation via balloon trocar. Tension was defined as a 50% decrease in cardiac output. Chest decompression was performed with 5-mm laparoscopic trocars for the treatment of both tPTX with hemodynamic compromise and tension-induced PEA. The lungs and heart were inspected and graded at necropsy for trocar-related injury. Results were also compared with success rates with NT in the same model.

The placement of a 5-mm trocar rapidly and immediately relieved tension physiology in 100% of the cases. Mean arterial pressure, cardiac output, central venous pressure, and pulmonary capillary wedge pressure all returned to baseline within 1 minute of trocar placement. Adequate perfusion was restored in 100% of tension-induced PEA cases within 30 seconds of trocar placement. There was no evidence of trocar-related heart or lung damage in any of the experimental animals at necropsy (mean injury scores, 0 for both). Fivemillimeter trocars significantly outperformed standard NT for both tPTX and tension-induced PEA arrest.

tPTX and tension-induced PEA can be safely and effectively treated with chest decompression using 5-mm laparoscopic trocars. This technique may serve as a more rapid and reliable alternative to needle decompression.

| Tags : pneumothorax