Clinical Practice and Cases in Emergency Medicine

Introduction: Needle thoracostomy is the only procedure in the United States for paramedic treatment of suspected tension pneumothorax within the most recent emergency medical services (EMS) national scope of practice model. We present a rare complication of an out-of-hospital left needle thoracostomy performed by paramedics after intracardiac placement of the catheter. The patient’s imaging studies in the receiving emergency department (ED) confirmed that the needle thoracostomy insertion location was correct, but the catheter entered the heart due to the patient’s existing atypical anatomy. 

Case Report: A 64-year-old unrestrained male driver in a roll-over motor vehicle accident was found in respiratory distress with difficulty auscultating left-sided lung sounds, left chest wall pain on palpation, and confusion. The first-arriving paramedics performed a left needle thoracostomy for suspected tension pneumothorax in advance of helicopter EMS transport. However, pulsatile blood flow from the catheter suggested intracardiac placement, which was confirmed on multiple imaging modalities in the ED. Imaging showed the catheter in the anterior second intercostal space at the midclavicular line. It was also revealed that the patient’s heart was prominently superior and nearly extended to the left chest wall with a majority of his left lung positioned posteriorly within the thorax. There were no signs of pneumothorax, hemothorax, subcutaneous emphysema, diaphragmatic injury, sternotomy wires, or other evidence that his atypical anatomy was the result of an exogenous process.

Conclusion: Intracardiac placement of a needle thoracostomy catheter is a rare complication. In this case, the patient’s atypical anatomy contributed to asymmetric lung sounds and suspicion of tension pneumothorax. Regardless of which insertion site was chosen, the likelihood of intracardiac placement was potentially high due to the patient’s anatomy. Anatomical variation can cause lung sound asymmetry that mimics a pneumothorax, which emergency clinicians and paramedics must consider when assessing for tension pneumothorax.