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12/01/2014

Exsufflation: 1 / 4 sans pneumothorax !

Inadequate Needle Thoracostomy Rate in the Prehospital Setting for Presumed Pneumothorax. An Ultrasound Study

Blaivas M.  J Ultrasound Med 2010; 29:1285–1289

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Nombreux ont attiré l'attention sur le risque d'inefficacité des exsufflations au cathéter à cause de la longueur de ces derniers, plus court que l'épaisseur de la paroi thoracique. Certains prônent l'emploi de cathéter de plus de 8 cm sans véritablement de fondements scientifiques (Lire cette analyse). Entre des mains peu expérimentées cette pratique apparaît dangereuse du fait du fait des erreurs faites sur les niveaux de ponction, ce d'autant que ces cathéters ne sont pas très efficaces dans le temps. L'article proposé incite encore plus à la nécessaire prudence à avoir avant de faire pénétrer une aiguille dans un thorax. En effet ce geste serait pratiqué 1 fois sur 4 en l'absence de pneumothorax. 

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Objective. The purpose of this study was to evaluate the frequency of inadequate needle chest tho-racostomy in the prehospital setting in trauma patients suspected of having a pneumothorax (PTX) onthe basis of physical examination.

Methods. This study took place at a level I trauma center. All trauma patients arriving via emergency medical services with a suspected PTX and a needle thoracostomy were evaluated for a PTX with bedside ultrasound. Patients too unstable for ultrasound evaluation before tube thoracostomy were excluded, and convenience sampling was used. All patients were scanned while supine. Examinations began at the midclavicular line and included the second through fifth ribs. If no sliding lung sign (SLS) was noted, a PTX was suspected, and the lung point was sought for definitive confirmation. When an SLS was noted throughout and a PTX was ruled out on ultrasound imaging, the thoracostomy catheter was removed. Descriptive statistics were calculated.

Results. A total of 57 patients were evaluated over a 3-year period. All had at least 1 needle thoracostomy attempted; 1 patient underwent 3 attempts. Fifteen patients (26%) had a normal SLS on ultrasound examination and no PTX after the thoracostomy catheter was removed. None of the 15 patients were later discovered to have a PTX on subsequent computed tomography. Conclusions. In this study, 26% of patients who received needle thoracostomy in the prehospital setting for a suspected PTX appeared not to have had a PTX originally, nor had 1 induced by the needle thoracostomy. It may be prudent to evaluate such patients with bedside ultrasound instead of automatically converting all needle thoracostomies to tube thoracostomies.

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Recourir à l'échographie pleurale et réaliser ce geste par voie latérale avec un cathéter de 5 cm apparaissent être sécuritaire.

20/12/2013

Drainage et thoracocentèse

Chest Drainage

McDermott S. et Al. Semin Intervent Radiol 2012;29:247–255

Infectious, traumatic, or neoplastic processes in the chest often result in fluid collections within the pleural, parenchymal, or mediastinal spaces. The same fundamental principles that guide drainages of the abdomen can be applied to the chest. This review discusses various pathologic conditions of the thorax that can result in the abnormal accumulation of fluid or air, and their management using image-guided methods.

10/12/2013

Thoracostomie au doigt: Le mieux !

Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews

Massaruttia D et Al. Eur J Emerg Med. 2006 Oct;13(5):276-80

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La réalisation d'une exsufflation à l'aiguille bien que classique reste discutable du fait de nombreux problèmes techniques et du caractère très relatif de son efficacité. La thoracostomie au doigt doit être considérée comme la technique de référence.

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OBJECTIVE:

To evaluate the effectiveness and potential complications of simple thoracostomy, as first described by Deakin, as a method for prehospital treatment of traumatic pneumothorax.

 

METHODS:

Prospective observational study of all severe trauma patients rescued by our Regional Helicopter Emergency Medical Service and treated with on-scene simple thoracostomy, over a period of 25 months, from June 1, 2002 to June 30, 2004.

RESULTS:

Fifty-five consecutive severely injured patients with suspected pneumothorax and an average Revised Trauma Score of 9.6+/-2.7 underwent field simple thoracostomy. Oxygen saturation significantly improved after the procedure (from 86.4+/-10.2% to 98.5%+/-4.7%, P<0.05). No difference exists in the severity of thoracic lesions between patients with systolic arterial pressure and oxygen saturation below and above or equal to 90. A pneumothorax or a haemopneumothorax was found in 91.5% of the cases and a haemothorax in 5.1%. No cases of major bleeding, lung laceration or pleural infection were recorded. No cases of recurrent tension pneumothorax were observed. Forty (72.7%) patients survived to hospital discharge.

CONCLUSIONS:

 

Prehospital treatment of traumatic pneumothorax by simple thoracostomy without chest tube insertion is a safe and effective technique.

| Tags : pneumothorax

01/09/2013

Pneumothorax: Pansement NON OCCLUSIF

Vented versus unvented chest seals for treatment of pneumothorax and prevention of tension pneumothorax in a swine model

Kheirabadi BS et all. J Trauma Acute Care Surg. 2013;75: 150-156

La procédure du sauvetage au combat indique qu'un thorax ouvert ne doit JAMAIS être fermé et qu'un pansement 3 côtés doit être mis en place  pour éviter toute surpression intrathoracique. Ceci diffère du TCCC américain qui recommande l'occlusion de la plaie et la surveillance du blessé à la recherche d'un pneumothorax suffocant. Mais les choses évoluent à la lumière de la remise en question de pratiques pas toujours bien documentées. Le TCCC va proposer le recours non pas à l'emploi d'un pansement 3 côtés consommateur de temps mais à l'utilisation de pansements adhésifs prêts à l'emploi.

L'article présenté montre très clairement l'intérêt de la mise en place de pansement permettant l'évacuation de l'air intrathoracique.

PneumoNonOcclusive.png

Au delà de l'intérêt des dispositifs prêts à l'emploi avec valve de surpression, il y a le problème du choix du modèle. La procédure du sauvetage au combat propose la valve d'asherman, qui doit être considérée comme obsolète car bien qu'efficace, sa capacité d'adhésion à la peau est perfectible. Il semble que les modèles concurrents (Hyfin Vent Chest Seal, SAM chest seal et Sentinel chest seal) proposés par l'industrie aient la même efficacité

02/07/2013

Pneumothorax: Dès 10 mmHg

Physiology and cardiovascular effect of severe tension pneumothorax in a porcine model

Nelson D et all. J Surg Res. 2013 Jun 5. pii: S0022-4804(13)00505-2

BACKGROUND:

Pneumothoraces are relatively common among trauma patients and can rapidly progress to tension physiology and death if not identified and treated. We sought to develop a reliable and reproducible large animal model of tension pneumothorax and to examine the cardiovascular effects during progression from simple pneumothorax to tension pneumothorax.

MATERIALS AND METHODS:

Ten swine were intubated, sedated, and placed on mechanical ventilation. After a midline celiotomy, a 10-mm balloon-tipped laparoscopic trocar was placed through the diaphragm, and a 28F chest tube was placed in the standard position and clamped. Thoracic insufflation was performed in 5-mm increments, and continuous cardiovascular measurements were obtained.

RESULTS:

Mean insufflation pressures of 10 mm Hg were associated with a 67% decrease in cardiac output (6.6 L/min versus 2.2 l/min; P = 0.04). An additional increase in the insufflation pressure (mean 15 mm Hg) was associated with an 82% decrease in cardiac output from baseline (6.8 versus 1.2 L/min; P < 0.01). Increasing insufflation pressures were associated with a corresponding increase in central venous pressure (from 7.6 mm Hg to 15.2 mm Hg; P < 0.01) and a simultaneous decrease in the pulmonary artery diastolic pressure (from 15 mm Hg to 12 mm Hg; P = 0.06), with the central venous pressure and pulmonary artery diastolic pressure approaching equalization immediately before the development of major hemodynamic decline. Pulseless electrical activity arrest was induced at an average of 20 mm Hg. Tension physiology was immediately reversible with adequate decompression, allowing for multiple repeated trials.

 

PhysioTamponnade.jpeg

CONCLUSIONS:

 

A reliable and highly reproducible model was created for severe tension pneumothorax in a large animal. Major cardiovascular instability proceeding to pulseless electrical activity arrest with stepwise insufflation was noted. This model could be highly useful for studying new diagnostic and treatment modalities for tension pneumothorax.

 

| Tags : pneumothorax

29/06/2013

Pneumothorax: A partir de quel volume d'air le dépiste-t-on ?

The intrapleural volume threshold for ultrasound detection of pneumothoraces: An experimental study on porcine models

Oveland NP et All. Scand J Trauma Resusc Emerg Med. 2013; 21: 11.

Pneumo.jpg

Tous les pneumothorax sont dépistés à l'échographie pour des volumes d'air de moins de 50 ml, de manière bien plus précoce que l'analyse d'une radiographie comme le montre la figure ci-dessus

| Tags : pneumothorax

10/11/2012

Exsufflation à l'aiguille: Pas si efficace ?

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

Martin M et All.J Trauma Acute Care Surg. 2012;00: 00Y00 (DOI: 10.1097/TA.0b013e31825ac511) 

Il existe un grand débat sur les modalités d'exsufflation d'un pneumothorax suffocant (site de ponction, longueur et calibre de l'aiguille, thoracostomie au doigt, drainage ?).

Ce travail expérimental pointe du doigt, UNE FOIS DE PLUS, les limites de l'exsuffflation à l'aguille:

"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%"

PTX REleif.JPG

Ces données doivent pousser plus avant la formation vers les deux autres moyens que sont l'exsufflation au doigt (présenté par beaucoup comme la méthode de référence) et bien sûr le drainage thoracique.

Approfondir: Document 1  Document 2  La réflexion US TCCC

01/10/2012

Epaisseur de paroi thoracique: Le point chez le militaire français

Mesure de l’épaisseur de la paroi thoracique chez des militaires français :

Quelle technique pour l’exsufflation du pneumothorax compressif lors du sauvetage au combat?

A propos d’une étude descriptive réalisée du 1er Mars au 15 Avril 2010

au 7ème Bataillon de Chasseurs Alpins de Bourg Saint Maurice.

LAMBLIN A. Thèse Lyon 2012

 

Le diaporama de présentation      :       EpThoDiaporama.pdf

La thèse                                          :       Lien

20/09/2012

Pneumothorax: La sonde d'écho à quel endroit ?

 Anatomical distribution of traumatic pneumothoraces on chest computed tomography: implicationsfor ultrasound screening in the ED

Mennicke M et alll. Am J Emerg Med 2012 Sep;30(7):1025-31

Un travail qui précise les zones optimales d'exploration de la région thoracique pour l'identiifcation optimale des pneumothorax traumatiques.

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OBJECTIVES:

We sought to assess the anatomical distribution of traumatic pneumothoraces (PTXs) on chest computed tomography (CT) to develop an optimized protocol for PTX screening with ultrasound in the emergency department (ED).

METHODS:

We performed a retrospective review of all chest CTs performed in one ED between January 2005 and December 2008 according to presence, location, and size of PTX. Pneumothoraces were then measured and categorized into 14 anatomical regions for each hemithorax.


RESULTS:

A total of 277 (3.8%) PTXs were identified, with 26 bilateral PTX, on 3636 chest CTs performed during the study period. Etiology was blunt (85%) or penetrating trauma (15%). Eighty-three (45%) PTXs were radiographically occult on initial chest x-ray. One hundred eighty-three (66%) PTX had no chest tube at the time of CT. For both hemithoraces, the distribution demonstrated increasing PTX frequency and size from lateral to medial and from superior to inferior. Region 12 (parasternal, intercostal spaces [ICS] 7-8) was involved in 68% of PTX on either side; region 9 (parasternal, ICS 5-6), in 67% on the left and in 52% on the right; and region 11 (lateral to midclavicular line, ICS 7-8), in 46% on the left and in 53% on the right. The largest anterior-to-posterior PTX dimension was seen in region 12.

zones thorax.jpg

Pneumothorax.jpg

CONCLUSIONS:

Our results indicate that 80.4% of right- and 83.7% of left-sided traumatic PTXs would be identified by scanning regions 9, 11, and 12. These findings suggest that a standardized protocol for PTX screening with ultrasound should include these regions.

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15/05/2012

Paroi thoracique: En moyenne 3,06 cm chez le japonais

JapanseseChestWall 1.JPG

The mean CWT measured in 192 males and 64 females was 3.06  1.02 cm. The CWT values at 483 sites (94.3%) were less than 5.0 cm. The CWT of females was significantly greater than that of males (3.66 cm vs. 2.85 cm, p < 0.0001), and patients with subcutaneous emphysema had greater CWTs than those without it (4.16 cm vs. 3.01 cm, p < 0.0001).

 

JapaneseChestWall.JPG

16/04/2012

3 Côtés: La valve de Russel

Outre qu'elle présente un dispositif type pansement 3 côtés, cette vidéo est intéressante par la qalité de la présenttaion clinique d'une plaie soufflante.

le thorax se soulève

la fréquence est rapide

la respiration n'est pas harmonieuse

car l'ampliation est faible avec tirage intercostal sans ballotement abdominal

le thorax est ouvert

le thorax souffle

http://www.prometheusmedical.co.uk/uploads/videos/RCS-sim...


Une vidéo de présentation technique

11/03/2012

Drainage Thoracique: Histoire de drain

A portable thoracic closed drainage instrument for hemopneumothorax.J Trauma. 2012;72: 671–675 Tang H; Pan T MD et all.

La pose d'un drain thoracique en préhospitalier s'impose dès lors qu'un pneumothorax n'est pas traité de manière correcte par une thoracostomie au doigt/Exsufflation à l'aiguille ou si l'évacuation du blessé est retardée. Le Front Line Chest Tube est l'équipement préconisé par la procédure du sauvetage au combat. Une alternative de fortune peut être une sonde d'intubation ou une canule de trachétomie. Cet article illustre le travail de réflexion fait pour mettre à disposition un équipement adapté au contexte pré-hopsitalier notamment militaire.  L'emploi de tubes à ballonet est proposé par des auteurs chinois qui ont dévelopé ce nouveau matériel présenté dans le Journal of Trauma

NewChestDrainage.jpg

23/02/2012

Exsufflation à l'aiguille: Le risque est rare mais réel !

Subclavian artery laceration: A serious complication of needle decompression

Riwoe D et all. Emergency Medicine Australasia (2011) 23, 651–653

Un article qui rapporte la survenue d'une dialcération de l'artère sous clavière après exsufflation à l'aiguille par voie antérieure. Les auteurs militent pour la réalisation d'une thoracostomie au doigt par voie latérale ou après repérage échographique sinon l'emploi de repère cutanés préconisés par Wax et coll. qui font appel à la reconnaissance de la fourchette sternale et la ligne médio-thoracique mamelonnaire.

Epaisseur de paroi thoracique: Une de plus qui dit le contraire!

Anterior Versus Lateral Needle Decompression of Tension Pneumothorax: Comparison by Computed Tomography Chest Wall Measurement.

Sanchez LD et all.  Academic Emergency Medicine 2011; 18:1022–1026

Un article qui présente des données qui contredisent le caractère plus épais de la paroi thoracique antérieure versus la paroi latérale, du moins au niveau des repères classiques d'exsufflation/Thoracostomie. La discussion n'est donc pas close. L'intérêt de ce document est aussi d'alerter sur le fait que le recours à de long cathéter peut améliroier le taux de succès d'une exsufflation mais aussi le risque de ponction de structures vasculaires sous jacentes.

paroitho.JPG

31/01/2012

Le triangle de sécurité pour la thoracostomie

Chest drain insertion is not a harmless procedure – are we doing it safely ?

Elsayed H. et All. Interactive CardioVascular and Thoracic Surgery 11 (2010) 745–749

Près de la moitié des drains thoraciques ne sont pas posés au bon endroit

thorax,drainage thorax

thorax,drainage thorax 

On rappelle la notion de triangle de sécurité (Le BTS Guideline)

TriangleSecurité.JPG

http://www.surgeryjournal.co.uk/article/S0263-9319%2811%2...

La réalisation d'une thoracostomie au doigt et l'insertion d'un drain doit se faire de manière sécuritaire.

Le choix de la voie axillaire est certainement à privilégier.

17/01/2012

Drainage de la plèvre: Techniques et pièges

Lisez donc ce document. Une synthèse du drainage pleural à l'hôpital. Révisez les repères

http://www.srlf.org/rc/org/srlf/htm/Article/2011/4ce9bc02...

 

06/01/2012

Passer par le côté, c'est mieux

J Trauma. 2011 Nov;71(5):1099-103; discussion 1103.

Optimal positioning for emergent needle thoracostomy: a cadaver-based study.

Source

Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California 90033-4525, USA. kinaba@surgery.usc.edu

Abstract

BACKGROUND:

Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate.

METHODS:

Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position.

RESULTS:

A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p < 0.001); right chest: 100% versus 60.0% (p = 0.003) and left chest: 100% versus 55.0% (p = 0.001). Overall, the thickness of the chest wall was 3.5 cm ± 0.9 cm at the fifth intercostal space and 4.5 cm ± 1.1 cm at the second intercostal space (p < 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm ± 1.0 cm vs. 4.5 cm ± 1.1 cm, p = 0.007; left, 3.5 ± 0.9 cm vs. 4.4 cm ± 1.1 cm, p = 0.008).

CONCLUSIONS:

In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.

26/11/2011

Exsufflation: 5 cm suffisent VRAIMENT !

Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan
Injury, In Press, Corrected Proof, Available online 24 December 2010
Takeshi Yamagiwa, Seiji Morita, Rie Yamamoto, Tomoko Seki, Katsuhiko Sugimoto, Sadaki Inokuchi
PDF (164 K) 

Background

Previous studies reported a high failure rate in relieving tension pneumothorax by needle thoracostomy, because the catheter was not sufficiently long to access the pleural space. The Advanced Trauma Life Support guideline recommends needle thoracostomy at the second intercostal space in the middle clavicular line using a 5.0-cm catheter, whereas the corresponding guideline in Japan does not mention a catheter length. It is necessary to measure the chest wall thickness (CWT) and determine the appropriate catheter length taking the differences of habitus in race and region into consideration. This study was designed to analyse CWT in Japanese trauma patients by computed tomography and to determine the percentage of patients whose pleural space would be accessible using a 5.0-cm catheter.

Patients and methods

We performed a retrospective review of chest computed tomography of 256 adult Japanese trauma patients who were admitted to the level 1 trauma centre of Tokai University Hospital in Kanagawa, Japan between January and July 2008. In 256 patients, the CWT at 512 sites (left and right sides) was measured by chest computed tomography at the second intercostal space in the middle clavicular line. The frequency of measurement sites <5.0 cm was calculated simultaneously.

The samples were divided according to gender, side (left and right), abbreviated injury scale (<3, ≧3), arm position during examination (up/down), and the existence or non-existence of associated injuries (pneumothorax, subcutaneous emphysema, and fracture of the sternum and ribs); the CWT of each group was compared.

Results

The mean CWT measured in 192 males and 64 females was 3.06 ± 1.02 cm. The CWT values at 483 sites (94.3%) were less than 5.0 cm. The CWT of females was significantly greater than that of males (3.66 cm vs. 2.85 cm, p < 0.0001), and patients with subcutaneous emphysema had greater CWTs than those without it (4.16 cm vs. 3.01 cm, p < 0.0001).

Conclusion

The mean CWT at the second intercostal space in the middle clavicular line was 3.06 cm. It is likely that over 94% of Japanese trauma patients could be treated with a 5.0-cm catheter.

Exsufflation:Au bon endroit !

Réaliser l'exsufflation au bon endroit n'est pas si simple, même quand on est censé être un professionnel !

RepèreExsufflation.JPG

The right place in the right space? Awareness of site for needle thoracocentesis
E P Ferrie EP et all.
Emerg Med J 2005;22:788–789. doi: 10.1136/emj.2004.015107

La procédure

15/11/2011

Exsuflation par voie antérieure: Au 5ème axillaire plutôt qu'au 2ème antérieur?

Optimal Positioning for Emergent Needle Thoracostomy: A Cadaver-Based Study

Inaba K et all. J Trauma. 2011;71: 1099–1103

Un travail de plus sur la pertinence de la remise en cause de la recommandation d'aborder la paroi thoracique au 2ème espace intercostal sur la ligne médioclaviculaire. Ces repères sont en rapport avec une plus grande profondeur de l'espace pleural source d'échec de décompression pleurale lors d'exsufflation à l'aiguille. Certains proposent de réaliser cette dernière par voie latérale.  Un  travail de plus qui conforte cette approche.

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Background: Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate.

 Methods: Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position.

 Results: A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity ( 0.001); right chest: 100% versus 60.0% ( 0.003) and left chest: 100% versus 55.0% ( 0.001). Overall, the thickness of the chest wall was 3.5 cm  0.9 cm at the fifth intercostal space and 4.5 cm 1.1 cm at the second intercostal space ( 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm 1.0 cm vs. 4.5 cm  1.1 cm, 0.007; left, 3.5  0.9 cm vs. 4.4 cm  1.1 cm, p 0.008).

Conclusion: In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.

Epaisseur.JPG