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Trick of the Trade: Don’t miss the pneumothorax in needle thoracostomy


PTXtensionA patient arrives in PEA arrest and you note that her left chest has no breath sounds or lung sliding on bedside ultrasound. You suspect a tension pneumothorax.

You insert a standard 14g angiocather in the left 2nd intercostal space (ICS). You don’t hear a rush of air. The patient’s clinical condition deteriorates to impending asystole. How sure are you that your angiocatheter actually reached the pleural space?

Trick of the Trade #1:

If aiming for the mid-clavicular 2nd ICS, go more lateral than you think. The clavicle ends in the shoulder, not the lateral chest wall! (1)

  • Ferrie et al study: Dots are where emergency physicians would have inserted an angiocatheter. Vertical line is the true mid-clavicular line.

Trick of the Trade #2:

Insert angiocatheter at the 5th ICS along the mid-axillary line, similar to the location of a chest tube.

  • Cadaver study by Inaba et al (2): Average chest wall thickness was 3.5 cm ± 0.9 cm at mid-axillary 5th ICS vs 4.5 cm ± 1.1 cm at mid-clavicular 2nd ICS
  • Success needle thoracostomy placement was 100% (5th ICS) vs 58% (2nd ICS)
  • Use at least a 5 cm angiocatheter.


Trick of the Trade #3:

Regardless of whether you use the mid-clavicular 2nd ICS or mid-axillary 5th ICS, use a longer angiocatheter than a traditional 3 cm IV angiocatheter. Otherwise it won’t reach the pleural space!

  • Example: Use the 6.3 cm angiocatheter often found in central line kits.
  • The average chest wall thickness at the 2nd ICS in a retrospective study in Canada was (3):

Thanks to Dr. Scott Weingart (@emcrit). Listen to the podcast for more tips and suggestions on this topic at his EMCrit blog!


  1. Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J. 2005 Nov;22(11):788-9. Pubmed. Free PDF article
  2. Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011 Nov;71(5):1099-103; discussion 1103. Pubmed .
  3. Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008 Jan;64(1):111-4. Pubmed .
Michelle Lin, MD
ALiEM Editor-in-Chief
Academy Endowed Chair of EM Education
Professor of Clinical Emergency Medicine
University of California, San Francisco
Michelle Lin, MD
Michelle Lin, MD

Latest posts by Michelle Lin, MD (see all)

  • The alternative is to just make an incision and dissect down with a hemastat, which should take no more than 15 sec and guarantees that you’re in the chest. You can then just throw in a chest tube right after, but the important part is to get the air out

  • Michelle,
    as always thanks for your trick of the trade posts, really love them.
    Wanted to comment alongside Jeff’s opinion, you might add trick #4,
    Finger Thoracostomy as mentioned in various blogposts and podcasts
    (first I found them with Cliff Reids’s and Scott Weingart’s blogs).

    Lately in an animal lab (with n=1 in every group 😉 we timed 5 sec finger th. vs almost 1 min full needle + tube…

    Any technique might be worthwhile knowing, the bigger our arsenal and the better we know our weapons the better, but knife+finger is surely one of the effective ones in this setting. Probably my first pick next time it comes up…

    • Alex: Thanks for your comments as always. Conceptually I have to agree that a finger thoracostomy best ensures that you are in the correct space. Institutionally, our trauma surgeons seem to be very opposed to opening the pleural space under anything less than the strictest sterile precautions. Glad to hear that many institutions have adopted the finger thoracostomy though. Hope it makes it more into the mainstream soon, perhaps with literature about infection rates so that I can cite the literature to our consultants.

      Let me know how your first finger thoracostomy goes. Looking forward to hearing about it!

  • Mike Takacs

    Very helpful on teaching needle thoracostomy!

  • Hey Mike! Thanks for commenting. I love this tip as well.

  • Love this post. Thanks Michelle.


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