- 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
- Clinical tension pneumothorax
- Local trauma: possibility of sharp bone fragment/foreign body
- sterile gloves
- Kelly clamp
- lidocaine, syringe, needle
- Recognize possible tension physiology.
- Locate 5th intercostal space at anterior/mid-axillary line.
- Clean with betadine.
- 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.
- Don sterile gloves.
- Using a No. 10/11 scalpel, make a 4cm through skin over and parallel to the superior border of the inferior rib.
- Using Kelly clamps, quickly blunt dissect through subcutaneous tissue and muscle just over the superior border of the inferior rib.
- 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
- 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)
- 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.
- If tension physiology confirmed on finger thoracostomy, place an urgent chest tube when resuscitation allows.
- 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
- slower to perform than needle decompression
- more steps/equipment than needle decompression
- no tube holding tract open; may seal off during resuscitation/movement/transport
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- 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.