OSCE Station: Needle Thoracocentesis for Tension Pneumothorax
Scenario:
A 7-year-old child presents to the emergency department with signs of tension pneumothorax following trauma. The patient is hemodynamically unstable with absent breath sounds on the right side, hypotension, and jugular venous distention. Your task is to perform a needle thoracocentesis.
1. Initial Assessment:
1.1 Recognize the Need for the Procedure:
Clinical features of tension pneumothorax include:
Severe respiratory distress.
Absent breath sounds on the affected side.
Hypotension and signs of obstructive shock (e.g., distended neck veins, cyanosis).
Tracheal deviation (late sign).
1.2 Explain the Indication for Needle Thoracocentesis:
Immediate needle thoracocentesis is performed to relieve pressure from a tension pneumothorax, a life-threatening condition that can compromise both respiratory and circulatory functions.
2. Equipment Preparation:
Materials Needed:
14-16 gauge catheter-over-needle (such as Medicath).
Alcohol swab for skin cleaning.
Sterile gloves.
3-way stopcock attached to a syringe.
Occlusive dressing or adhesive plaster.
Sterile drape.
Forceps (to clamp the needle and prevent it from advancing too deeply).
3. Patient Positioning:
Position the patient in a supine position with the head elevated slightly (semi-Fowler’s position), which helps access the chest wall.
4. Procedure Steps:
4.1 Identifying the Correct Site:
Identify the second intercostal space (ICS) in the mid-clavicular line on the affected side (e.g., right side if the patient has right-sided pneumothorax).
Palpate the second rib and insert the needle just above the third rib (avoiding the neurovascular bundle).
Alternatively, you can choose the 5th intercostal space (ICS) in the anterior axillary line if the anterior chest is inaccessible.
4.2 Insertion Technique:
Clean the area with an alcohol swab.
Clamp the needle using forceps near the base to prevent it from advancing too deeply into the chest. This prevents excessive penetration, ensuring safe access to the pleural space.
Connect the 3-way stopcock to the catheter before insertion. This ensures that the system is closed, preventing air from escaping before you are ready to control it.
Insert the catheter-over-needle at a 90-degree angle, directly above the third rib to avoid the neurovascular bundle. Advance until you feel a pop, indicating entry into the pleural space.
Use the syringe and stopcock to carefully aspirate air. Monitor for relief of tension pneumothorax, taking care not to kink the catheter during the process.
Do not remove the metal needle from the catheter at this stage. Keep the system intact with the stopcock connected to maintain control of air release.
4.3 Management After Insertion:
Continue to aspirate air until the patient shows signs of improvement, such as coughing, or until no more air can be aspirated.
Leave the catheter in place with the 3-way stopcock to allow continued air removal if needed.
Cover the site with an occlusive dressing to avoid further air entry.
Key Points:
In this modified technique, you do not listen for air release ("hiss") before connecting the 3-way stopcock because the system must remain closed from the start to prevent additional air from entering or uncontrolled release.
5. Post-procedure Monitoring:
Monitor the patient’s hemodynamic status continuously.
Confirm relief of tension pneumothorax by reassessing:
Breath sounds.
Respiratory effort.
Blood pressure stabilization.
Summary for OSCE:
Identify clinical signs of tension pneumothorax (absent breath sounds, hypotension, tracheal deviation).
Prepare equipment: 14G needle, catheter, 3-way stopcock, and forceps.
Choose the correct insertion site (2nd ICS, midclavicular line or 5th ICS, anterior axillary line).
Clamp the needle with forceps to prevent excessive penetration.
Connect the 3-way stopcock before insertion to ensure a closed-loop system.
Insert needle above the rib, aspirate air through the 3-way stopcock, and monitor the patient.
Stop air aspiration when the patient coughs or no more air can be drawn out.
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