NCD 14ga vs ?

   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.