Exsufflation: 5 cm suffisent !

Can J Surg. 2010 June; 53(3): 184–188

Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length

Ball CG et all.

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Résumé

Needle thoracostomy decompression was attempted in 1.5% (142/9689) of patients. Among patients with blunt injuries, the incidence was 1.4% (101/7073). Patients transported by helicopter (74%) received a 4.5-cm sheath. The remainder (26% ground transport) received a 3.2-cm catheter. A minority in each group (helicopter 15%, ground 28%) underwent immediate chest tube insertion (before thoracic ultrasound) because of ongoing hemodynamic instability. Failure to decompress the pleural space by NT was observed via ultrasound and/or CT in 65% (17/26) of attempts with a 3.2-cm catheter, compared with only 4% (3/75) of attempts with a 4.5-cm catheter (p < 0.001).

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Morceau choisi

Although some authors^13,16 have called for 7- to 8-cm needles to ensure that all OPTXs are decompressed, it appears that even catheters as short as 4.5 cm can puncture the heart at standard insertion locations in 2.5% of trauma patients.²⁴ Other complications include chest wall hematoma, hemothorax, empyema and dislodgement in up to 8% of patients.^18,25 In an attempt to avoid these issues, as well as access the pleural space more reliably, support for axillary NT is increasing.^{3,18,22,25,39} This lateral location takes advantage of a thinner chest wall (mean 2.6 cm)¹⁶ and is the military’s first choice if under fire because it allows medics to keep a soldier’s body armor in place while achieving decompression.⁴⁰ Although we observed no direct complications in our study, we support the use of a catheter at of least 4.5 cm in length.

Commentaires

Le pneumothorax suffocant est la seconde cause de mort évitable au combat. Sa pris en charge repose sur la décompression de l'air retneu dans la cage thoracique. Outre la thoracostomie au doigt, geste de référence simple et sans danger, il peut être effectué une décompression à l'aiguille. Certains militent pour l'emploi d'un cathéter de grande taille de 8 cm du fait de l'épaisseur de la paroi thoracique, en particulier chez les militaires . Cependant le risque de plaie cardiaque et des gros vaisseaux est relativement important et peut atteindre 2.5% des blessés (1, 2, 3), ce d'autant plus que les ponctions sont habituellement réalisées de manière beaucoup trop médianes.

En condition de combat, une conduite raisonnable est de pratiquer cette exsufflation par voie LATERALE (4) et par ailleurs d'utiliser des cathéters de 5 cm qui apparaissent SUFFISANTS (5)