Intercostal Space In Midclavicular Line Research Articles

A Retrospective Analysis of Needle Thoracostomies at a Tertiary Level 2 Trauma Center.

A tension pneumothorax is a condition that results in elevated pressure within the pleural space. The effective management of tension pneumothorax relies on needle decompression, commonly performed at the second intercostal space (ICS) midclavicular line (MCL). However, some literature suggests that catheters placed in the second intercostal space midclavicular line are prone to higher failure rates compared to the fifth intercostal space midaxillary line (MAL) (42.5% versus 16.7%, respectively). In this study, we aim to identify and scrutinize the prevalence of prehospital needle decompression from one tertiary care center over eight years and examine their trends, efficacies, or pitfalls. It is hypothesized that preclinical providers are performing needle decompression prematurely and unnecessarily. A set of 90 patient records obtained using the trauma registry at Saint Francis Hospital, Tulsa, Oklahoma, were retrospectively reviewed to evaluate the management and outcomes of tension pneumothorax, as well as the indications documented for needle decompression. Patient charts were reviewed via Epic Hyperspace (Epic, Madison, WI). The Oklahoma Emergency Medical Service Information System (OKEMSIS) also provided information contributing to the sample population. The most documented indications for needle decompressions included diminished or absent breath sounds (52.70%), hypoxia (15.54%), hypotension, and hemodynamic instability (6.76%). Emergency medical services (EMS) reported improvements in 51 (56.67%) patients after needle thoracostomy. Improvements in vital signs after needle decompression were sporadic. The most common complication was catheter dislodging, which occurred most in the second intercostal space midclavicular line. Only nine patients had an oxygen saturation (SpO2) below 92% and a systolic blood pressure (SBP) below 100 mm Hg prior to receiving needle decompression. Current practices for tension pneumothorax show little improvement in vital signs before and after needle decompression. Vital signs prior to needle decompression often do not indicate tension pneumothorax physiology. Preclinical providers may be inappropriately performing needle decompressions, an invasive procedure with complications.

Paramedic Understanding of Tension Pneumothorax and Needle Thoracostomy (NT) Site Selection.

IntroductionTension pneumothorax is an immediate threat to life. Treatment in the prehospital setting is usually achieved by needle thoracostomy (NT). Prehospital personnel are taught to perform NT, frequently in the second intercostal space (ICS) at the mid-clavicular line (MCL). Previous literature has suggested that emergency physicians have difficulty identifying this anatomic location correctly. We hypothesized that paramedics would also have difficulty accurately identifying the proper location for NT.MethodsA prospective, observational study was performed to assess paramedic ability to identify the location for treatment with NT. Participants were recruited during a statewide Emergency Medical Services (EMS) conference. Subjects were asked the anatomic site for NT and asked to mark the site on a shirtless male volunteer. The site was copied onto a transparent sheet lined up against predetermined points on the volunteer’s chest. It was then compared against the correct location that had been identified using palpation, measuring tape, and ultrasound.Results29 paramedics participated, with 24 (83%) in practice for more than five years and 23 (79%) doing mostly or all 9-1-1 response. All subjects (100%) reported training in NT, although six (21%) had never performed a NT in the field. Nine paramedics (31%) recognized the second ICS at the MCL as the desired site for NT, with 12 (41%) specifying only the second ICS, 11 (38%) specifying second or third ICS, and six (21%) naming a different location (third, fourth, or fifth ICS). None (0%) of the 29 paramedics identified the exact second ICS MCL on the volunteer. Mean distance from the second ICS MCL was 1.37 cm (interquartile range (IQR): 0.7-1.90) in the medial-lateral direction and 2.43 cm in the superior-inferior direction (IQR: 1.10-3.70). Overall mean distance was 3.12 cm from the correct location (IQR: 1.90-4.50). Most commonly, the identified location was too inferior (93%). Allowing for a 2 cm radius from the correct position, eight (28%) approximated the correct placement. 25 (86%) were within a 5 cm radius.ConclusionIn this study, paramedics had difficulty identifying the correct anatomic site for NT. EMS medical directors may need to rethink training or consider alternative techniques.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Failure of First Attempt Needle Decompression in Tension Pneumothorax: Case Report

Tension pneumothorax can occur as a potentially life threatening complication of chest trauma. Tension pneumothorax is commonly treated with needle decompression, both the 2nd intercostal space in the midclavicular line and the 4th/5th intercostal space in the anterior axillary. A 45 years old man came to our emergency department after blunt injury of the chest presenting tension pneumothorax with unstable hemodynamic treated with needle decompression using 14 gauge (4.5 cm) cannula at 2nd intercostal space mid clavicular line, patient successfully recover and became hemodynamic stable, after 30 minutes of successful needle decompression patient experienced with recurrent tension pneumothorax. Several studies show the failure of needle decompression it may due to several factor such as chest wall thickness, cannula length, and location of the needle decompression. In this case the cannula may has insufficient length (4.5 cm) to pass through the full thickness of the patient’s chest wall at 2nd intercostal space mid clavicular line (ICS 2) and makes air leaks from the lung faster than it can escape through the cannula.

Sonographic assessment of pediatric chest wall thickness and width of the intercostal space: correlation with anthropometric data and implications for needle decompression

BackgroundEmergent needle decompression in children is a rare event for emergency medicine and critical care providers. Hereby, risk of injury of intrathoracic structures is high and knowledge of age-specific values of chest wall thickness and width of the intercostal space (ICS) is crucial to avoid injuries. Investigation of the correlation of chest wall thickness and width of the intercostal space with age and body dimension like weight and height could provide guidance on depth of insertion and choice of the needle.MethodsWe performed a prospective observational clinical trial in a pediatric surgery operating room that included a convenient sample of children aged 0–10 years undergoing elective surgery. Chest wall thickness and width of the intercostal space were measured with ultrasound at 2nd ICS midclavicular line (MCL) and 4th ICS anterior axillary line (AAL). Correlation of these measures with age, height, weight, BMI and Broselow color was calculated. Furthermore, intra-class correlation coefficient was calculated as a measure of reproducibility and the presence of vital structures (e.g., heart, thymus gland, large pulmonary vessels) at the possible insertion sites for needle decompression was investigated.ResultsOf 410 potentially eligible patients, 300 were included in the study. Correlation of chest wall thickness was moderate with weight (2nd ICS MCL: r = 0.57; 4th ICS MCL: r = 0.64) and BMI (r = 0.44 and r = 0.6) and was lower with age (r = 0.38 for both intercostal spaces), height (r = 0.42 and r = 0.40) and Broselow color (r = 0.42 and r = 0.38). Correlation of width of the ICS with anthropometric data was generally stronger, with height showing the strongest, albeit not really strong, correlation (r = 0.71 and r = 0.62). Intra-class correlation was excellent with an ICC of 0.93. Vital structures were significantly more often present at 2nd ICS MCL then at 4th ICS AAL (14 vs. 2 patients; p = 0.0042).ConclusionsCorrelation of chest wall thickness and width of the intercostal space with anthropometric data is at most moderate. Insertion depth and width of the intercostal space can therefore not be predicted accurately from anthropometric data. Ultrasound assessment of the thoracic wall appears to be a reliable technique and could therefore assist in reducing the risk of injury and increasing decompression success.Trial registration German clinical trials register, DRKS00014973, Registered February 11th 2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014973

The Nipple as a Landmark for Needle Decompression of Tension Pneumothorax in Children – A CT-Based Evaluation and Proposal of an Alternative Insertion Site

Objective Needle decompression of tension pneumothorax in children is a rarely encountered but potentially life-saving procedure, that is accompanied by a certain risk of injury. We evaluated the nipple as a landmark for an alternative anterior insertion site and as an aid in localizing lateral insertion sites, as well as its influence on the safety profile of the procedure. Methods In thoracic computer tomography scans of children aged 0–10 years, the distance to the closest vital structure was compared between the traditional anterior insertion site (2nd intercostal space midclavicular line) and an alternative anterior insertion site (2nd intercostal space at the nipple line). Furthermore, the level of the nipple at the midaxillary line was investigated as guidance in quickly localizing the lateral insertion site and ensuring an insertion site high enough to avoid intraabdominal injury by the decompression needle. Additionally, correlation of these measures with age was investigated. Results The distance to the closest vital structure at the 2nd intercostal space was significantly bigger at the nipple line compared to the midclavicular line (right: 2.23 ± 1.13 cm vs. 0.99 ± 0.80 cm, p < 0.0001; left: 1.92 ± 1.19 cm vs. 0.81 ± 0.70 cm, p < 0.0001). At the midaxillary line, the level of the nipple was at the 4th or 5th intercostal space in the majority of children (right: 83.8%; left: 88.1%). The mean distance from the nipple to the diaphragmatic cupola was 2.63 ± 1.85 cm on the right and 3.40 ± 1.86 cm on the left hemithorax. Conclusion When performing anterior needle decompression in children, we recommend inserting the needle at the more lateral insertion site at the 2nd intercostal space at the nipple line. At the lateral decompression sites, the nipple can be used as a marker for localizing the correct intercostal space for insertion and thereby ensuring enough caudad distance to the diaphragm to avoid abdominal injury.

Changing Trends in the Decompression of Tension Pneumothorax

Tension Pneumothorax (TP) is one of the commonest complication of chest trauma. For many years the management for tension pneumothorax decompression was the immediate insertion of a wide bore Cather (14-16 gauge) into the 2nd intercostal space (ICS) in mid-clavicular line (MCL) followed by the insertion of a chest tube in the 5th ICS anterior to the mid-axillary line (MAL). In 2018 the Advanced Trauma life support (ATLS) guidelines has changed and the ideal place for tension pneumothorax decompression is at the 5th intercostal space anterior to the MAL. The thickness of the chest wall is significantly less at the 5th intercostal space MAL when compared to 2nd ICS in MCL, and that an 8 cm length Cather has a better efficacy in comparison to 5 cm catheter, as proved by radiographic measurements. In our article we reviewed the literature in response to the new policy in different countries.

Failure Rate of Prehospital Needle Decompression for Tension Pneumothorax in Trauma Patients

Tension pneumothorax is commonly treated with needle decompression (ND) at the 2nd intercostal space midclavicular line (2nd ICS MCL) but is thought to have a high failure rate. Few studies have attempted to directly measure the failure rate in patients receiving the intervention. We performed a retrospective analysis of 10 years of patients receiving prehospital ND. CT scans were reviewed to record the location of catheters left indwelling and the proportion of patients who did not have any pneumothorax. Chest wall thickness was measured on both injured and uninjured sides at the 2nd ICS MCL and compared with the recommended alternative, the 5th ICS anterior axillary line (5th ICS AAL). We identified 335 patients that underwent prehospital ND who had CT scans performed. Using our two different radiologic methods of assessing failure, 39 per cent and 76 per cent of attempts at ND failed to reach the pleural space. In addition, at least 39 per cent of patients did not have a tension pneumothorax. Injured chest walls were significantly thicker than uninjured chest walls at both the 2nd ICS MCL and the 5th ICS AAL (both P < 0.005.) Increasing chest wall thickness correlated with the failure of the catheter to reach the pleural space. Using an 8-cm catheter at the 5th ICS AAL, iatrogenic cardiac injury was at risk in 42 per cent of patients. This series confirms the high failure rate of ND at the 2nd ICS MCL, but further studies are needed to assure the safety of using larger catheters at the 5th ICS AAL.

ULTRASOUND MEASUREMENT OF CHEST WALL THICKNESS IN ELITE RUGBY PLAYERS; A COMPARISON BETWEEN THE NEEDLE THORACOCENTESIS SITES

AimsThere are no known published studies to support current pitch side guidelines for the management of a tension pneumothorax in a sporting population (1). Temporary management of this condition involves...

Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter.

Decompression of tension physiology may be lifesaving, but significant doubts remain regarding ideal needle thoracostomy (NT) catheter length in the treatment of tension physiology. We aimed to demonstrate increased clinical effectiveness of longer NT angiocatheter (8 cm) compared with current Advanced Trauma Life Support recommendations of 5-cm NT length. This is a retrospective review of all adult trauma patients from 2003 to 2013 (age > 15 years) transported to a Level I trauma center. Patients underwent NT at the second intercostal space midclavicular line, either at the scene of injury, during transport (prehospital), or during initial hospital trauma resuscitation. Before March 2011, both prehospital and hospital trauma team NT equipment routinely had a 5-cm angiocatheter available. After March 2011, prehospital providers were provided an 8-cm angiocatheter. Effectiveness was defined as documented clinical improvement in respiratory, cardiovascular, or general clinical condition. There were 91 NTs performed on 70 patients (21 bilateral placements) either in the field (prehospital, n = 41) or as part of resuscitation in the hospital (hospital, n = 29). Effectiveness of NT was 48% until March 2011 (n = 24). NT effectiveness was significantly higher in the prehospital setting than in the hospital (68.3% success rate vs. 20.7%, p < 0.01). Patients who underwent NT using 8 cm compared with 5 cm were significantly more effective (83% vs. 41%, respectively, p = 0.01). No complications of NT were identified in either group. Eight-centimeter angiocatheters are more effective at chest decompression compared with currently recommended 5 cm at the second intercostal space midclavicular line. Therapeutic study, level IV.

Dextrocardia and symmetric hypertrophic cardiomyopathy with multiple mutations of genes encoding the sarcomere proteins

Solitus inversus dextrocardia, or mirror type dextrocardia, is a veryrare malposition with the prevalence around 0.1‰ and often presentsin Kartagener Syndrome [1,2]. Albeit a cardiac anomaly and hereditaryanatomicalvariation,solitusinversusdextrocardiaisanisolatedcardiacpositional anomaly and combining other congenital cardiac defects arequite uncommon in mirror-type dextrocardia, with the prevalence ofonly 3% [3], which is much lower when compared to solitus situsdextrocardia[4].Intheaccompanieddefects,hypertrophiccardiomyop-athy(HCM)isdefinitelyinfrequentandonlyseveralcaseshavebeenre-ported [5]. As a common hereditary cardiac disease, the occurrence ofHCM is supposed to be related to the mutation of genes encoding thesarcomere proteins[6]. Around5%ofpatients carry more than onemu-tation in patients with HCM in China [7]. We reported a case of mirror-type dextrocardia who developed HCM in adulthood exhibiting multi-ple genetic mutation related to sarcomere proteins.A 43-year-old nonsmoker male presented with repeated chest dis-comfort for more than 5 years and deteriorated for half a month. Hewas diagnosed as dextrocardia (mirror-image type) without detectingany other congenital cardiac anomaly at 6-year-old by an X-ray. In thefollowing 3 decades, his exercise ability was normal without recurrentrespiratory tract infections or sinusitis. At 38 years old, he developedcrushing retrosternal pain after physical exertion and was mitigated atrest. Physical examination showed that his blood pressure was 140/80 mm Hg without systolic murmur and the blood pressure differencebetweenlowerand upper extremitieswasless than20mmHg. Cardiacapex palpation was on the right 5th intercostal space in mid-clavicularline. Dextrocardia was demonstrated with cardiomegaly and normallungfieldontheX-ray(Fig.1).OnthestandardECG,rightaxisdeviationwas visible with positive QRS in aVR lead, inversion of all complex inlead I and dominant S waves in the chest leads (Fig. 2A). All thesesigns were normal after reversing limb leads and placing chest leadson the right except the hypertrophic sign of left ventricle (Fig. 2B).Transthoracicechocardiographyrevealedthatmirror-typedextrocardiawithsolitusinversus,atrioventricularconcordant,normalconnectionofventricular–arterial connection. Moreover, significant symmetric leftventricular hypertrophy (30 mm of the septum and 30 mm of the

Impalement injuries of the left thorax, abdomen and axilla by reinforced iron rods—a case report

A 29-year-old male labourer fell on iron rods at a construction site which pierced through his abdomen and thorax. One rod, 5 ft long, entered the left hypochondrium injuring the transverse colon, spleen and entering the thorax through the diaphragm going through the superior segment of the lower lobe of the left lung and further going through the upper lobe touching the lateral pericardial surface and coming out through the second intercostal space midclavicular line. Another rod, 3 ft long, pierced the left axilla, sparing the axillary vessels and major nerves. The rods were successfully removed along with superior segmentectomy and repair of upper lobe injuries. Abdominal injury required diaphragm repair, colon repair and splenectomy. The patient made an uneventful recovery without any sequelae.

Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax

Five-centimeter needles at the second intercostal space midclavicular line (2MCL) have high failure rates for decompression of tension pneumothorax. This study evaluates 8-cm needles directed at the fourth intercostal space anterior axillary line (4AAL). Retrospective radiographic analysis of 100 consecutive trauma patients 18 years or older from January to September 2011. Measurements of chest wall thickness (CWT) and depth to vital structure (DVS) were obtained at 2MCL and 4AAL. 4AAL measurements were taken based on two angles: closest vital structure and perpendicular to the chest wall. Primary outcome measures were radiographic decompression (RD) (defined as CWT < 80 mm) and radiographic noninjury (RNI) (DVS > 80 mm) of 8-cm needles at 4AAL. Secondary outcome measures are effect of angle of entry on RNI at 4AAL, RD and RNI of 8-cm needles at 2MCL, and comparison of 5-cm needles with 8-cm needles at both locations. Eighty-four percent of the patients were male, with mean Injury Severity Score (ISS) of 17.7 (range, 1.0-66.0) and body mass index of 26.8 (16.5-48.4). Mean CWT at 4AAL ranged from 37.6 mm to 39.9 mm, significantly thinner than mean CWT at 2MCL (43.3-46.7 mm). Eight-centimeter needle RD was more than 96% at both 4AAL and 2MCL. Five-centimeter RD ranged from 66% to 81% at all sites. Mean DVS at 4AAL ranged from 91.8 mm to 128.0 mm. RNI at all sites was more than 91% except at left 4AAL, when taken to the closest vital structure (mean DVS, 91.8 mm), with 68% RNI. Perpendicular entry increased DVS to 109.4 mm and subsequent RNI to 91%. Five-centimeter RNI at all sites was more than 99%. CWT at 4AAL is significantly thinner than 2MCL. Based on radiographic measurements, 8-cm catheters have a higher chance of pleural decompression when compared with 5-cm catheters. Steeper angle of entry at 4AAL improves 8-cm noninjury rates to more than 91%. Therapeutic/care management study, level IV.

A rare case of Kartagener′s syndrome

A young boy presented with cough and intermittent breathlessness for 3 months. He used to suffer from frequent cough and cold since childhood. Clinical examination revealed bilateral coarse basal crepitations and rhonchi. His apex beat was on right 5th intercostal space in mid-clavicular line. Investigation revealed situs inversus, bi-lateral bronchiectasis, and chronic sinusitis. His semen analysis revealed the complete absence of sperm. The Saccharin test revealed impaired nasal ciliary movement. Considering all the finding, he was diagnosed as a case of Kartagener's syndrome. We are reporting this case because of its rarity and rare presence of aspermia in Kartagener's syndrome.

Do mannequin chests provide an accurate representation of a human chest for simulated decompression of tension pneumothoraxes?

Tension pneumothorax (TPX) is an uncommon but life-threatening condition. It is important that this uncommon presentation, managed by needle decompression, is practised by paramedics using a range of educationally sound and realistic mannequins. The objective of this study is to identify if the chest wall thickness (CWT) of training mannequins used for chest decompression is an anatomically accurate representation of a human chest. This is a two-part study. A review of the literature was conducted to identify chest wall thickness in humans and measurement of chest wall thickness on two commonly used mannequins. The literature search was conducted using the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, and EMBASE databases from their beginning until the end of May 2012. Key words included chest wall thickness, tension pneumothorax, pneumothorax, thoracostomy, needle thoracostomy, decompression, and needle test. Studies were included if they reported chest wall thickness. For the literature review, 4 461 articles were located with 9 meeting the inclusion criteria. Chest wall thickness in adults varied between 1.3 cm and 9.3 cm at the area of the second intercostal space mid clavicular line. The Laerdal(®) manikin in the area of the second intercostal space mid clavicular line, right side of the chest was 1.1 cm thick with the left 1.5 cm. The MPL manikin in the same area or on the right side of the chest was 1.4 cm thick but on the left 1.0 cm. Mannequin chests are not an accurate representation of the human chest when used for decompressing a tension pneumothorax and therefore may not provide a realistic experience.

Needle Decompression for Tension Pneumothorax in Tactical Combat Casualty Care: Do Catheters Placed in the Midaxillary Line Kink More Often Than Those in the Midclavicular Line?

Tactical Combat Casualty Care (TCCC) is a system of prehospital trauma care designed for the combat environment. Needle decompression (ND) is a critical TCCC intervention, because previous data suggest that up to 33% of all preventable deaths on the battlefield result from tension pneumothoraces. There has recently been increased interest in performing ND at the fifth intercostal space in the midaxillary line to prevent complications associated with landmarking second intercostal space in the midclavicular line site. We developed a model to assess whether catheters placed in the midaxillary line for decompressing tension pneumothoraces are more prone to kinking than those placed in the midclavicular line because of adducted arms during military transport. To simulate ND, we secured segments of porcine chest walls over volunteer soldiers' chests and placed 14-gauge, 1.5-inch angiocatheters through the porcine wall segments which were affixed to either the midaxillary or midclavicular location on the volunteers. We then assessed for occlusion and kinking by flow of normal saline (NS) through the angiocatheter in situ. The angiocatheter was then transduced using standard arterial line manometry, and the opening pressures required to initiate flow through the catheters were measured. The opening pressures were then converted to mm Hg. We also assessed for catheter occlusion after the physical manipulation of the patient, by simulated patient transport. We observed that there was a significant pressure difference required to achieve free flow through the in situ angiocatheter between the fifth intercostal space midaxillary line versus the second intercostal space midclavicular line site (13.1 ± 3.6 mm Hg vs. 7.9 ± 1.8 mm Hg). This study suggests that the 14-gauge, 1.5-inch angiocatheter used for ND in the midaxillary line may partially and temporarily occlude in patients who will be transported on military stretchers. The pressure of 12.8 mm Hg has been documented in animal models as the pressure at which hemodynamic instability develops. This may contribute to the reaccumulation of tension pneumothoraces and ultimate patient deterioration in military transport.

Spontaneous pneumothorax management

BACKGROUND: The purpose of the present study was to evaluate the current practice habits among clinicians treating primary spontaneous pneumothorax. METHODS: Practice habits were investigated in 55 pulmonologists, 75 general surgeons, 23 thoracic surgeons, all were chiefs of their respective departments, by a postal survey. The mail contained a cover letter requesting the recipients' participation and explaining the purpose of the research and a survey questionnaire. RESULTS: Ninety-seven respondents (63%) included 28 pulmonologists (28/55, 52%), 48 general surgeons (49/75, 64%) and 20 thoracic surgeons (20/23, 87%). Sixty-nine respondents treat first primary spontaneous pneumothorax with chest tube, 25% by simple observation and 6% by aspiration. Seventy four percent of respondents insert chest tube in the second intercostal space midclavicular line and 22% in the fourth intercostal space midaxillary line. Nearly 71% of pulmonologists use <18 F chest tube, 85% of thoracic surgeons insert 20–24 F chest tube. Chest tubes are initially placed to suction by 56% of respondents. Chest tube clamping prior its removal is employed by 74% of clinicians. CONCLUSIONS: Marked practice variation exists in clinicians' approaches to the management of primary spontaneous pneumothorax that is partially explained by differences between pulmonologists and surgeons, and also between thoracic and general surgeons.

Needle Thoracostomy in the Treatment of a Tension Pneumothorax in Trauma Patients: What Size Needle?

A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5-cm (2-inch) catheter (5-cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle. To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces. Retrospective review of major trauma admissions (Injury Severity Score >12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, <40 years of age and >/=40 years of age was defined a priori. CWT was measured to the nearest 0.01 cm at the second ICS in the MCL. The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50 cm at the left second ICS MCL and 3.51 cm on the right. The mean CWT was significantly higher for women than men (p < 0.0001). About 9.9% to 19.3% of the men had a CWT >4.5 cm and 24.1% to 35.4% of the women studied. A catheter length of 4.5 cm may not penetrate the chest wall of a substantial amount (9.9%-35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy.

Haemopneumothorax after fine needle aspiration of the breast

We must congratulate Dr Whitaker and his team for correctly diagnosing a tension pneumothorax and saving the patient’s life with subsequent needle thoracocentesis (November 2003 JRSM1). The tension had arisen 32 hours after a diagnostic fine needle aspiration (FNA) of the left upper outer quadrant of the breast. However, we disagree that the ensuing haemothorax was caused by the FNA and feel it was far more likely to be caused by the needle thoracocentesis. At operation the lesion was found to be at the apex of the lung which in the normal lung lies above the clavicle, higher than where the FNA was performed. Needle thoracocentesis for a tension pneumothorax at the 2nd intercostal space midclavicular line is much more likely to hit the apex of the lung and cause haemothorax.

Hemoglobinuria Following Closed Cardiac Massage

To the Editor.— Frank hemoglobunuria as a complication of cardiac massage must be rare. We recently observed this unique (self-limiting) complication after vigorous massage. Report of a Case.— A 78-year-old white man suffered a dull, aching, and persistent retrosternal pain for four days. He was in no distress. The blood pressure was 116/70 mm Hg; pulse, 68 beats per minutes and regular. Fundi showed arteriosclerotic changes. Neck veins were flat. The apex of the heart was in the fifth intercostal space in midclavicular line. The sounds were normal. The lungs were clear. Shortly after admission, cardiac arrest occurred. The physician started vigorous closed-chest cardiac massage with a hard board under the patient's mattress. The emergency team arrived within two minutes. An electrocardiographic tracing showed ventricular fibrillation. The patient was intubated and defibrillated, with the cardiac rhythm returning to normal. The first sample of urine, passed four hours after the cardiac