HWN Suggests

Finger Thoracostomy

Though there have been no published studies that side by side compare the finger to the needle, it is likely that the finger has the advantage in terms of preventing recurrent tension physiology. At the end of the day, if you have a patient crashing in front of you from a tension hemopneumothorax, a finger thoracostomy is the only way to know for sure you got into the thorax and relieved the tension physiology.

read full article

Featured

 EM@3AM: Pneumothorax

Tension pneumothorax should be diagnosed clinically and treated immediately with needle decompression. Use a 14-gauge needle, at least 5 cm long, with a syringe to aspirate. Alternatively, perform finger thoracostomy for decompression. A pigtail catheter may be left in place, attached to suction or a Heimlich valve. Placement at the 4th/5th intercostal space in the anterior axillary line has lower failure rates compared to the traditional 2nd intercostal space in the mid-clavicular line.

Articles of Interest

Needle Decompression

Forget the “traditional” needle decompression landmark. Decompress at 4th or 5th intercostal space in the anterior axillary line.

Prehospital finger thoracostomy in patients with chest trauma

Finger thoracostomy has been implemented in some prehospital settings for patients who are not spontaneously breathing in response to concerns regarding the effectiveness of needle thoracostomy.

Simple Thoracostomy: Moving Beyond Needle Decompression in Traumatic Cardiac Arrest

To avoid the complications associated with needle decompression, a number of services in Europe have adopted simple thoracostomy as an option for chest decompression. Simple thoracostomy is a technique similar to the placement of a chest tube, traditionally done in the ED. It utilizes an incision with a scalpel and penetration directly into the thoracic cavity with forceps and a gloved finger to relieve the tension pneumothorax. The only major difference is that the chest tube isn’t inserted.

What is the Best Anatomic Location for Needle Thoracostomy?

Best evidence suggests that the 4th/5th ICS-AAL has the lowest predicted failure rate of needle decompression with a 5cm angiocatheter.

Resources

First10EM

A loosely collated collection of thoracic procedures videos that I have found helpful for teaching.

Life in the Fastlane

If the patient persists in a shocked state during transport, the thoracostomy can be “re-fingered” to ensure the lung is up, thus excluding one cause of obstructive shock.

WikEM

Remove the Kelly clamps from the tract and insert your full gloved finger into the space. intrapleural palpation confirms access of the pleural space. re-expansion of the lung parenchyma may be palpated, especially if patient is receiving positive pressure ventilation (e.g. intubated).