So recently asked why TCCC still recommends 14 gauge vs 10 gauge. Or for that matter why not some other device? A brief scan of literature didn't readily yield and back to back comparison of needle gauges. Anecdotally some say the 10 gauge is less likely to kink.
Additionally, there are now several new products which might be used.
1) ThoraQuick from Medical Tree (UK) - slick product with spring loaded blunt tip that allows penetration of skin whilst reducing risk of injury to underlying structures once in the thoracic cavity. It is essentially an improvement on the Turkel needle (see below) with an improved hub that allows for easy adhesion to the pt's chest wall. 2 ports on side of catheter as additional protection against occlusion. Length of catheter: 10cm, Size: 3mm ID (approx. 8 ga). Cost: 33.95 sterling or $47.96? (Not sold in US yet)
2) Turkel Needle: Also from Medical Tree. Spring loaded blunt tip. Catheter length: 3.5" (88.9cm), Size: 8 Fr (11.5 ga). Cost $60.99. (Available now)
3) 10 Fr (10 ga) Thoracotomy Tube with trocar. The IDF has been using a Vygon 10 Fr trocar with drain. This was originally designed for tube thorocostomy in neonates. The tube material is stiffer than the usual polyurethane in the 14 ga needle. The argument being it further helps prevent kinking and thus failures. A recent article (see below) discussed this but failed to directly compare the two devices and was limited by small sample size.
It is my opinion that the real reason CoTCCC may still be recommending the 14 gauge catheter may have a lot to do with cost. A 14 gauge needle/cath with hard case cost $9.99 from NAR. Even if you have to use multiple per pt, it's still cheaper, and it's a well established item in the supply chain. Add to that the lack of hard data showing superiority of other devices and it may be that a good solution now is better than a perfect solution later.
Beyond which is better there is some argument that perhaps we should abandon the needle altogether and go to finger thoracotomies both in the ED and in the field. See Scott Weingart's post about this as well as an article in JEMS below.
In the meantime I would say if you want to carry a 10 gauge, Turkel needle or the hot new ThoraQuick - go for it! There certainly is no data so suggest any of these options in inferior. And in the meantime if all you can get is a 14 gauge angiocath - do sweat it. Know the problems that may arise (kinking, clotting, risk of injury to intrathoracic structure) and anticipate the problems and have a plan.
Emerg Med J 2011;28:750-753
J. Chen et. al. " Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience", Canadian Journal of Surgery, Vol 58 (3) Supplement 3, June 2015.
M Escott, et al. "Simple Thoracostomy: Moving Beyond Needle Decompression in Traumatic Cardiac Arrest" JEMS 39(4), MAR 2014.
Current TCCC guidelines advocate the use of 14g, 3.25" (80mm) needle. This recommendation evolved after studies looking at chest wall length demonstrated that the average size angiocath (1.77") would fail in as many as 50% of patients on the battlefield (1).
A newer study by the UK military revisited not just chest wall thickness, but also distance to vital structures from the 2 recommended needle thoracostomy sites- 2nd intercostal space MCL and 5th intercostal space mid axillary line. Several interesting points were made. First, was that chest wall thickness averaged about 37mm at 2ICS MCL and 34.5mm at 5ICS MAL. Second, that if the standard 3.25 in (80mm) needle decompression device was placed in the chest wall to the hub, injury to underlying vital structures (diaphragm, heart, aorta, pulmonary arteries) would occur in 21% of patients. (3)
It should be noted that there are several limitations to this paper. It was retrospective, involved only 63 patients, of which all were young healthy males. The UK averages for chest wall thickness were smaller than US studies for chest wall thickness. US chest wall averages published were 48.6-53.6 mm depending on angle of needle through chest wall. (2) The Harke paper noted that chest wall thickness increased with age and in females, but the majority of those studied can still be treated with the 3.25" needle.
1) Current needle decompression needle length of 3.25" (80 mm) should be long enough for 99% of the studied population.
2) DO NOT HUB the needle. Going too far can be just as bad as not going far enough.
3) Parallel to chest wall has shorter distance than parallel to floor/litter.
1. Stevens RL, Rochester AA, Busko J, et al. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehospital Emergency Care 2009;13:14-17.
2. Harke HT, Pearse LA, Levy AD, et al. Chest wall thickness in military personnnel: implications for needle thoracentesis in tension pneumothorax. Military Medicine. 2007; 172:1260-1263.
3. J Chen, R Nadler, D Schwartz, H Tein, A Cap, E Glassberg. What is the optimal device length and insertion site for needle thoracostomy in UK military casualties? Can J Surg. 2015 Jun;58(3 Suppl 3):S118-24. PMID: