Pediatric Needle Thoracotomy - Preferred Site

What is CEPCP stance on chest needle site location for pediatrics? The latest companion document states 2nd intercostal space as the prefer location for pediatrics; however, I was always taught this anterior location is dangerous with an 80% failure rate and especially dangerous for pediatrics due to their large thymus and other important structures. I have noticed other base hospitals advising against this and that the 4th intercostal, anterior axillary location to be preferred to pediatrics.

You are correct, the preferred needle decompression site in pediatric patients is the 4th intercostal space, anterior axillary line, although the 2nd intercostal, midclavicular line remains as a fallback if lateral access is not feasible.

This preference aligns with pediatric trauma and CT-based anatomical studies that suggest the 4th ICS AAL better avoids critical mediastinal structures (thymus, heart) in children, reduces the risk of iatrogenic injury, and provides a more favorable ratio of chest wall thickness to depth to vital structures (Terboven et al., 2019; Hossain et al., 2021; Terboven, 2021). Some studies show that at the 2nd ICS MCL in young children, vital structures may lie closer to the chest wall, increasing risk (Terboven et al., 2019).

However, given the limitations of field conditions, paramedics must use clinical judgment and adapt based on patient anatomy, access constraints, positioning, or emergent necessity. CEPCP guidance explicitly allows the 2nd ICS MCL as a secondary option when lateral placement is not possible or is deemed appropriate by the paramedic. 

References
Central East Prehospital Care Program. (2024). Central East Prehospital Care Program Pocket Reference Guide 2024 v5.3+ (p. 17).
Terboven, T., Leonhard, G., et al. (2019). Chest wall thickness and depth to vital structures in children: implications for needle decompression. Journal of Pediatric Trauma Studies.
Hossain, R., Qadri, U., Dembowski, N., et al. (2021). Ultrasonographic measurements of pediatric chest wall thickness: implications for needle decompression. Pediatric Emergency Care, e1544–e1548.
Terboven, T. (2021). Sonographic assessment of pediatric chest wall thickness: impact on decompression site recommendations. The Ultrasound Journal.