Paediatric Acute care Guidelines PMH Emergency Department

Needle Thoracocentesis

  • Needle Thoracocentesis provides rapid emergency decompression of a tension pneumothorax
  • It is a temporary life saving procedure – a  definitive chest drain will be required to stabilise the ongoing air leak
Clinical evidence of a tension pneumothorax:  
  • Hypoxia
  • Hypotension 
  • Tachycardia
  • Decreased air entry +/- hyperresonance on side of pneumothorax
  • Deviated trachea to opposite side
  • Increased difficulty in ventilation

Radiographic evidence of a tension pneumothorax in a haemodynamically stable patient

  • 14g or 16g cannula
  • 3-way tap
  • 10mL syringe
  • 2% Chlorhexidine/70% isopropl alcohol
  • Identify the second intercostal space, mid clavicular line of affected hemi thorax
  • Cleanse the skin 
  • Consider local anaesthetic in the conscious child (if time permits) 
  • Attach 10mL syringe to the end of the cannula
  • Insert the cannula into the lower half of the second intercostal space, at 90º to the chest wall
  • Aspirate the syringe as the needle enters
  • Continue advancing the cannula until you aspirate air (3-4ml of 0.9% saline in the syringe may help with presence of air bubbles) or until you insert to the maximum depth
  • At either of these end points remove the syringe and needle, leaving the cannula in the chest wall
  • Check for improvement of the child’s clinical condition
  • A 3-way tap may be applied for ongoing aspiration, if required
  • Consider a second needle decompression if there is no apparent improvement
    • 1cm adjacent to the original cannula 
  • Proceed to chest drain insertion as soon as possible when patient is stabilised
  • Perform the CXR after the formal chest drain has been placed

Intercostal Catheter Insertion 

  • An intercostal catheter provides drainage of pleural air, blood or fluid
  • Following a needle decompression of tension pneumothorax
  • Large pneumothoraces (> 20%)
  • Most traumatic haemathoraces
  • Large pleural effusions
  • 2% Chlorhexidine/70% isopropl alcohol
  • Sterile surgical drapes, gown, mask
  • Sterile gloves
  • Local anaesthetic, syringe and needle
  • Gauze
  • Scalpel blade
  • Forceps for blunt dissection
  • Chest drain – without trochar
  • Suture – 2.0 silk
  • Sterile transparent occlusive dressing
  • Atrium draining system (underwater seal drain) 
  • 2 x large chest drain clamps


Chest Tube Size 
Size: approximately (in Fr) 4 x ETT size (in mm)
Age  Chest tube size (Fr) 
Newborn  8-12
Infant  14-20
Child  20-28
Adolescent  28-36


  • Position Patient
    • Supine or sitting 30º upright
    • Arm on affected side positioned above the shoulder behind the head

IC Catheter patient position

  • Consider the need for adjunctive analgesia or sedation
    • Within limits of patient safety as determined by the clinical scenario
    • e.g. intranasal fentanyl or intravenous morphine
  • Identify insertion site 
    • Typically 5th intercostal space anterior to mid-axillary line

IC Catheter Insertion site

  • Prepare skin with 2% Chlorhexidine/70% isopropl alcohol
  • Drape area
  • Infiltrate local anaesthetic 
    • Superficially under the skin
    • Advance needle fully until air aspirated from pleural cavity
    • Slowly withdraw and infiltrate from deep to superficial
  • Perform skin incision in the identified rib space parallel to rib (above the lower rib to avoid neurovascular bundle) 
    • Length: approximately twice the width of the drain
    • Depth: until subcutaneous fat is on view
  • Blunt dissect through remainder of the chest wall using blunt dissection forceps
    • Continue until the pleural space is penetrated (evidenced by a “give” or air hiss) 
  • Remove instruments and insert finger through the tract into the pleural space
    • Perform a single sweep with finger internally within the pleural space 
    • This is only possible in older children
  • Insert chest drain, without trochar, into pleural space
    • Using forceps to guide the drain, if necessary
    • Aim for apex if draining air and base if draining fluid
  • Insertion depth is approximately the width of the hemithorax – ensure all holes in chest drain are within pleural space
  • Connect chest drain to underwater seal drain
  • Check for fogging of the tube, bubbling of underwater seal or swing of blood, fluid
  • Suture drain in place
  • Place an occlusive dressing over the area
  • Confirm position with CXR
  • Secure connection of chest drainage system with cable ties
This open technique for chest drain insertion should be used for all trauma patients. A Seldinger technique using commercial intercostal drain kits may be used for spontaneous pneumothoraces or pleural effusions after discussion with senior clinicians. 

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