- Patients with hypotension (SBP <90), clinical signs of shock, and at least one of the following signs:
- Jugular vein distention.
- Tracheal deviation away from the side of the injury (often a late sign).
- Absent or decreased breath sounds on the affected side.
- Hyper-resonance to percussion on the affected side.
- Increased resistance when ventilating a patient.
- Patients in traumatic arrest with chest or abdominal trauma for whom resuscitation is indicated. These patients may require bilateral chest decompression even in the absence of the signs above.
- Don personal protective equipment (gloves, eye protection, etc.).
- Administer high flow oxygen.
- Identify and prep the site:
- Locate the second intercostal space in the mid-clavicular line on the same side as the pneumothorax. If unable to place anteriorly, lateral placement may be used at the fourth ICS mid-axillary line. Prepare the site with providone-iodine ointment or solution.
- Insert the catheter (14 gauge for adults) into the skin over the third rib and direct it just over the top of the rib (superior border) into the interspace.
- Advance the catheter through the parietal pleura until a “pop” is felt and air or blood exits under pressure through the catheter, then advance catheter only to chest wall.
- Remove the needle, leaving the plastic catheter in place.
- Secure the catheter hub to the chest wall with dressings and tape.
- Consider placing a finger cut from an exam glove over the catheter hub. Cut a small hole in the end of the finger to make a flutter valve. Secure the glove finger with tape or a rubber band. (Note – don’t waste much time preparing the flutter valve; if necessary control the air low through the catheter hub with your gloved thumb.)