Finger thoracostomy

Overview

• The finger thoracostomy is an alternative to needle thoracostomy for emergent decompression of a suspected tension pneumothorax
• Numerous studies suggest that needle thoracostomy inconsistently accesses the pleural space
• This alternative procedure allows for tactile (+/- visual) feedback that the pleural space has been accessed
• Will cause an open pneumothorax.
• Has not been studied head-to-head against needle thoracostomy
  • Thus, any advantages/disadvantages are currently based on expert opinion rather than strong evidence

Indications

• Clinical tension pneumothorax

Contraindications

• Local trauma: possibility of sharp bone fragment/foreign body

Equipment Needed

• sterile gloves
• scalpel
• Kelly clamp
• betadine
• lidocaine, syringe, needle

Procedure

Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) directly under the ribs.

1. Recognize possible tension physiology.
2. Locate 5th intercostal space at anterior/mid-axillary line.
3. Clean with betadine.
4. Consider lidocaine/local anesthetic: reconsider if in a trauma code, or based on urgency of access/stability of patient.
   • If patient is awake/alert, anesthetize the skin, muscle and down to pleura.
5. Don sterile gloves.
6. Using a No. 10/11 scalpel, make a 4cm through skin over and parallel to the superior border of the inferior rib.
7. Using Kelly clamps, quickly blunt dissect through subcutaneous tissue and muscle just over the superior border of the inferior rib.
8. With closed Kelly clamps, puncture through the parietal pleura.
   • the "give" of the parietal pleura indicates access of the pleural space
   • if tension hemopneumothorax is present, you may hear a "whoosh" of air or note swift return of blood
9. 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)
10. If lung is already expanded on palaption and there is no forceful air/fluid release, it may be possible to close the thoracic wound with occlusive dressing, obviating further tube thoracostomy.
11. If tension physiology confirmed on finger thoracostomy, place an urgent chest tube when resuscitation allows.

Advantages

• advantages over needle thoracostomy:
  • unlimited by needle length
  • observable signs confirming pleural access
    • puncture sensation of parietal pleura with Kelly/finger
    • palpation of parietal pleura with finger
    • palpation of lung parenchyma with finger
  • if no pneumothorax, will not puncture lung parenchyma to create new pneumothorax
    • theoretically does not require placement of chest tube if no initial pneumothorax
  • no chance of catheter "kinking"
• advantages over tube thoracostomy
  • simpler: quicker, easier, less equipment
  • no foreign body, decreased infection

Disadvantages

• slower to perform than needle decompression
• more steps/equipment than needle decompression
• no tube holding tract open; may seal off during resuscitation/movement/transport

See Also

• tension pneumothorax
• needle thoracostomy
• chest tube

External Links

• https://emcrit.org/emcrit/needle-finger-thoracostomy/
• http://regionstraumapro.com/post/38306629710
• http://www.tamingthesru.com/blog/acmc/finger-thoracostomy

References

• Fitzgerald M, Mackenzie CF, Marasco S, Hoyle R, Kossmann T. Pleural decompression and drainage during trauma reception and resuscitation. Injury. 2008 Jan;39(1):9-20. doi: 10.1016/j.injury.2007.07.021. Review. PubMed PMID:18164300.
• Stevens RL, Rochester AA, Busko J, Blackwell T, Schwartz D, Argenta A, Sing RF. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7. doi: 10.1080/10903120802471998. PubMed PMID: 19145519.
• Ball CG, Wyrzykowski AD, Kirkpatrick AW, Dente CJ, Nicholas JM, Salomone JP, Rozycki GS, Kortbeek JB, Feliciano DV. Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Can J Surg. 2010 Jun;53(3):184-8. PubMed PMID: 20507791; PubMed Central PMCID: PMC2878990.
• Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. Needle

thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008 Jan;64(1):111-4. doi: 10.1097/01.ta.0000239241.59283.03. PubMed PMID: 18188107.

• Deakin CD, Davies G, Wilson A. Simple thoracostomy avoids chest drain insertion in prehospital trauma. J Trauma. 1995 Aug;39(2):373-4. PubMed PMID:7674410.