Search

The right 2nd interspace minithoracotomy has advantages over femoral arterial cannulation providing an alternative that should be in the arsenal of the minimally invasive surgeon; we describe here the method, the advantages, and the pitfalls.

Objectives: Needle decompression of tension pneumothorax in soldiers of the French infantry has a risk for failure when the standard procedure that involves the insertion of a 14-gauge, 5-cm catheter into the 2nd intercostal space (ICS) is used. This study measured the chest wall thickness (CWT) to assess whether this approach is appropriate. Methods: CWT was measured by ultrasound in 122 French soldiers at the 2nd and 4th ICSs on both the right and left sides. Results: CWT was measured at 4.19 cm (±0.96 cm) at the 2nd ICS and 3.00 cm (±0.91 cm) at the 4th ICS (p < 0.001). CWT was greater than 5 cm in 24.2% of cases at the 2nd ICS and 4.9% of cases at the 4th ICS (p < 0.001). Conclusions: This study suggests a high risk of failure when using the technique currently taught in the French army. A lateral approach into the 4th ICS could decrease this risk. The results of this study must be validated in patients presenting tension pneumothorax.

Background Displacement of ECG leads can result in unwarranted findings. We assessed the frequency of Brugada-type patterns in athletes when precordial leads were purposely placed upward. Methods Four hundred ninety-one collegiate athletes underwent two ECGs: one with standard leads, one with V1 and V2 along the 2nd intercostal space. A positive Brugada-type pattern was defined as ST elevation in V1 or V2 consistent with a Type 1, 2, or 3 pattern in the high-lead ECG. A control group was comprised of 181 outpatients. Results No Type 1 patterns were seen. In 58 athletes (11.8%), a Brugada-type 2 or 3 pattern was observed. Those with Brugada-type 2 or 3 patterns were more likely male, taller, and heavier. In the control group, 18 (9.9%) had Brugada-type 2 or 3 patterns and were more likely male. Conclusions Proper lead positioning is essential to avoid unwarranted diagnosis of a Brugada-type ECG, especially in taller, heavier male athletes.

We report supravalvular aortic stenosis in a 12 year old patient who presented with mental retardation, malformed teeth, broad lower lips, pectus carinatum, clinodactyly, kyphoscoliosis with symptoms of shortness of breath. On examination presence of better volume pulse in right radial artery with ejection systolic murmur best heard in right 2(nd) intercostal space were noted. Patient was diagnosed as having William's syndrome with investigations demonstrating Supravalvular aortic stenosis with a gradient of 170 mm Hg.

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.

This study was a retrospective investigation of computed tomography (CT) images of an Australian adult hospital population. These images were used to evaluate the spatial relationships of the superior vena cava (SVC) to the midsagittal line, the sternal paracoronal plane, and commonly used landmarks of the sternum. Consistent relationships were found between the long axis of the SVC and both the midsagittal line and sternal paracoronal plane. When the sternal paracoronal plane was used as the plane of reference, the angle of Louis was found to approximate the SVC in 99.5% of cases, and the right 2nd intercostal space approximated the SVC in 94% of cases. Constraints on the use of landmarks are discussed with regard to magnetic guidance systems for catheter tracking.

Advanced Trauma Life Support guidelines recommend the use of a cannula 3 to 6 cm long to perform needle thoracocentesis for life-threatening tension pneumothorax. The chest wall thickness in the 2nd intercostal space, mid-clavicular line, was determined by ultrasound in 54 patients aged 18 to 55 years, and ranged from 1.3 to 5.2 cm (mean 3.2 cm). In thirty-one patients (57 per cent) the chest-wall thickness (CWT) was greater than 3 cm, the minimum recommended cannula length, although in only two (4 per cent) was it greater than 4.5 cm, the length of cannula commonly used in the UK. As a 3 cm cannula would fail to reach the pleural cavity in over half of patients, we suggest that the recommended shortest length be increased to 4.5 cm. Unsuccessful needle thoracocentesis using a 4.5 cm cannula should be followed immediately by insertion of a longer cannula or a definitive chest drain.