We talked about needle thoracostomy a while back and when we did, we talked about the propensity for the needle to fail. There are a lot of reasons why the needle could fail to relieve a tension pneumothorax (or to only temporarily relieve a tension pneumothorax). The needle may be too short to enter the thorax in the first place* or the catheter could kink, allowing reaccumulation of air in the thorax.
*As a quick aside, the literature that focuses on these topics focus primarily on standard 16G or 14 G angiocaths (or they don’t mention what size angiocaths were used in the first place), not the big mamma jamma 10G angiocaths at our disposal.
Where's the Evidence?
The use of a “simple thoracostomy” a.k.a “finger thoracostomy” was initially described in the literature in 1995. Deakin, Davies, and Wilson described the use of a simple finger thoracostomy in the prehospital environment by a HEMS system in London. 45 patients, all with pnuemothorax or hemothorax suspected, all with GCS < 8, and all intubated, had the simple thoracostomy performed as opposed to tube thoracostomy. The advantages of this procedure over a tube thoracostomy are quite apparent. It is faster. It doesn’t involve the placement of a foreign body (and the potentially increased risk of infection that would come along with it). And, it is easier to teach and perform than an entire tube thoracostomy.
Massarutti, et al (2006) published their experience with this procedure in the PHARM environment (Friuli-Venezia Giulia in northern Italy). They describe 55 patients receiving simple thoracostomy in the field over a 2 year period of time. Their indications for the procedure were multiple rib fractures, flail chest, diminished breath sounds, and subcutaneous emphysema. (note these are far more liberal inclusion criteria than the initial study) Before the procedure 24% of patients had low O2 sat (<90) and low SBP (< 90 mmHg). On performance of the procedure, they found pneumothorax or a hemopneumothorax in 91.5% of cases. After the performance of the procedure, there was no recurrence of tension physiology. They didn’t document any infectious complications but their methods for follow up are not well described.
The FOAMed world has written much on this topic, with well-reasoned arguments in the pro camp (Scott Weingart and Minh Le Cong - here) as well as con camp (Michael McGonigal @regionstraumapro - here). 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.
How to Perform the Procedure
If you perform the finger thoracostomy, you need to know what you are doing. Take a look at the videos below showing Dr. Hinckley walking through the procedure. Careful attention to anatomic landmarks is CRUCIALLY important to avoid complications such as perforation into the abdominal cavity. Using sterile technique (as sterile as is possible) is also crucially important to avoiding infectious complications.
Procedural Slide Set
First Person Video
- Deakin, C., Davies, G., & Wilson, A. (1995) Simple thoracostomy avoids chest drain insertion in prehospital trauma. The Journal of Trauma: Injury, Infection, and Critical Care. 39(2). 373-374.
- Masarutti, D., Trillo, G., Berlot, G., Tomasini, A., Bacer, B., D’Orlando, L., Viviani, M., Rinaldi, A., Babuin, A., Burato, L., & Carchietti, E. (2006) Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews. European Journal of Emergency Medicine. 13. 276-280.