Vascular injury during needle thoracentesis: Need for a change in landmarks. A case report and review of the literature

Haemothorax following emergency needle thoracentesis [NT] for tension pneumothorax [TP] is a rare though serious complication [1]. We present a case of massive haemothorax, subsequent to the transection of the first intercostal artery by a misplaced needle during thoracentesis. The case highlights the need for emphasis upon precise and safe location of the landmarks for the procedure. The authors suggest replacing the teaching of the safe interventional landmark, from the currently advocated [along the upper border of the lower rib], to the safer site of the [middle of the intercostal space]. We also propose that resuscitation manuals and courses should stress locating the [angle of Louis] or the manubro-sternal angle to correctly identify the second rib. A 23 year old male presented to the emergency department with 2 hour history of sudden onset, left sided chest pain and shortness of breath. The patient had no history of any significant previous illnesses or allergies. A non-smoker, he was not on any regular medications. Physical examination showed he was not distressed, haemodynamically stable [blood pressure 112/85 mmHg] and maintaining an oxygen saturation of 97% on room air. There was decreased air entry in the left upper chest with a hyper-resonant percussion note. The rest of the systemic examination was unremarkable. A working diagnosis of spontaneous pneumothorax was made. This was confirmed by a chest X-ray which showed nearly 50% collapse of the left lung [Fig.1]

Biparietal diameter: significant gender difference is present in later weeks of gestation

Objective of this study was to find the presence and significance of difference in biparietal diameter values of male and female fetuses of local population at 35 weeks of gestation. Study was conducted at Lahore General Hospital, and partly in Sir Ganga Ram Hospital/Fatima Jinnah Medical College, Lahore, Pakistan in the year 2005. Outer to inner biparietal diameter in 60 normal singleton fetuses was measured at 35 weeks of gestation. Among them 30 fetuses were male and 30 females. All had comparable values of femur length and fetal abdominal circumference. Mean BPD and standard deviation were calculated for the total, male and female groups separately. Mean BPD in total 60 patients was 87.1 mm, SD2.6. Mean BPD of male group was 88.4mm, SD2, while that of female group was 85.9mm, SD2.4. Lower limit of 2SD range was accordingly different. When lower 2SD limit of male group was used, significant [P<0.05] number [23%] of female fetuses showed BPD<2SD. Using common mean and SD, 13% females showed BPD<2SD, while use of female specific mean and SD showed normal distribution. Biparietal diameter values at 35 weeks of gestation are significantly different in fetuses of each sex. Mean BPD of female fetuses at 35 weeks is 2mm shorter than mean BPD of male fetuses of same age. Male fetuses have a relatively narrow range of normal BPD; and this parameter can be used in males for reliable estimation of gestational age. Females have relatively wider range of normal BPD. Female BPD seems to be responsible for wider range of common nomograms. This parameter alone should not be used for age estimation or diagnosis of small for dates, or microcephaly, in later weeks of gestation in females. Gender specific BPD nomograms may improve the prenatal assessment of fetal growth and structural anomalies