Written by Clay Smith
A standard 5cm 14-16 gauge needle for chest decompression was more than twice as long as needed for children < 13 years old based on CT chest wall thickness (CWT).
Why does this matter?
ATLS recommends a 5cm (2 inch) 14-16 gauge needle to decompress suspected tension pneumothorax to ensure enough length to get into the pleural space and simply says to use caution in kids. But in children, it should not be so long as to injure underlying lung parenchyma or vital structures. What is the best length for children?
Long enough but not too long
This was a study of CWT on 250 CT scans in children of various ages from 0-13 years.
Median CWT at the second intercostal space, mid-clavicular line (2nd ICS-MCL) was stratified by Broselow length and color. Also, recent adult studies suggest the fourth intercostal space, anterior axillary line (4th ICS, AAL) might result in a higher success rate; so, this measurement was performed as well.
Broselow color (height); CWT 2nd ICS-MCL; CWT 4th ICS-AAL
Gray/Pink (<68cm); 1.57cm; 1.67cm
Red/Purple (68.1-90cm), 1.96cm; 1.73cm
Yellow/White (90.1-115cm), 2.12cm; 1.91cm
Blue/Orange/Green (>115.1cm), 2.45cm; 2.19cm
This means a standard length 14-16 gauge catheter, which is 1.5 inches (3.8cm) long, would have been adequate for all children <13 years old, unless morbidly obese. This would be an excellent addition to the back side of the Broselow tape.
Handtevy is a slick, customizable app that helps EMS get doses and equipment sizes correct for pediatric patients, such as large needles for decompression. To learn more, see their site. I have no financial interest in Handtevy. I just heard about it, tried the demo, and thought it was pretty nice!
REBEL EM covered an article on CWT and alternative placement than 2nd ICS, MCL.
Appropriate Needle Length for Emergent Pediatric Needle Thoracostomy Utilizing Computed Tomography. Prehosp Emerg Care. 2019 Jan 9:1-10. doi: 10.1080/10903127.2019.1566422. [Epub ahead of print]
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Reviewed by Thomas Davis