Finger Thoracostomy

Wellingon Free Ambulance Guidelines

Considered in patients who:

- Are in extremis and at immediate risk of death

- Have undergone, or are about to undergo, RSI

- Have an established or evolving tension pneumothorax

- Are failing to respond to standard resuscitation

- Patients at risk of developing a tension pneumothorax

Consultation with the medical director

Not covered under a specific CPG

Higher rate of survival

19% of patients who received needle decompression died on arrival at hospital versus 7% of patients who received tube thoracostomy

Barton, E., Epperson, M., Hoyt, D., Fortlage, D., & Rosen, P. (1995). Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience with aeromedical crews.

Published in 1995

Modified technique developed as a faster and simpler alternative to a formal chest tube

Has important advantages over conventional techniques

Only for patients who are not spontaneously breathing

Technique first used by London HEMS

Deakin, D., Davies, G., & Wilson, A. (1995). Simple thoracostomy avoids chest drain insertion in prehospital trauma. The Journal of Trauma , 39 (2), 373-374.

Further literature

Massaruttia, D., Trillo, G., Berlota, G., Tomasinia, A., Bacerb, B., D’Orlandoa, L., et al. (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 (5), 276-280.

- Two-year prospective observational study

- Examined 55 severe trauma patients who received a finger thoracostomy

- In 96.6% of the patients, a pneumothorax, haemothorax, or haemopneumothorax was found

- No reports of a recurrent tension pneumothorax

- Only highly trained crews should perform the procedure

The Procedure

- Prep the skin

- Scalpel incision through the skin

- Artery clip + gloved finger through the intercostals

- Pleural puncture

- Touch lung

Finger Thoracostomy

Diagnostic Clearance

A quick and efficient way to rule out a tension pneumothorax

- Clinical signs of tension pneumothorax can be unreliable

Less complications

Negative for pneumothorax? Occlusive dressing

No reports of infection from the studies

Less likely to cause infection than a chest tube (5%)

No reports of major bleeding

No reports of lung injury

Finger Thoracostomy

Tension Pneumothorax

- Pathophysiology

- Needle Thoracostomy

- Finger Thoracostomy

- Recommendations

Adam Stevenson

Recommendations

Summary

Give them the finger!

- The traditional treatment of needle decompression comes with high clinical risk and unacceptable failure rates

- The newly developed technique of finger thoracostomy has proven to be safe and effective

- It has important clinical advantages for the treatment of ventilated patients

- Needle decompression still has a role for spontaneously breathing patients

Further develop guidelines and advanced training for the use of finger thoracostomy in the prehospital setting

Procedure to come under the delegated scope of practice for Intensive Care Paramedics

Continued research should examine the effectiveness and safety of this procedure when used autonomously by intensive care paramedics.

Problems

Needle Thoracostomy

Needle inserted into the pleural space

Air aspirated

Tension relieved

- Needle length

- Needle diameter

- Location

- Occlusion and kinking

- Iatrogenic injury

- Diagnostic clearance

Tension Pneumothorax

Breach in the visceral, parietal, mediastinal pleura

Progressive buildup of air causing intrapleural pressure to rise

Complete lung collapse

Midiastinal shift

Imapired hemodynamics

+

Asphyxial hypoxemia

=

Compromised cardiac output

CARDIAC ARREST

Occlusion and Kinking

Location

Diagnostic Clearance

Needle Length

Needle Diameter

High intrathoracic pressures compress and kink the cannula

Second intercostal space, midclavicular line

Needle failure or no pneumothorax?

Won't reach in up to 65% of patients

Designed to go soft at body temperature

- Traditional site

- Taught by the NZRC

Case reports

No studies exist showing the sensitivity of needle thoracostomy when used diagnostically

Ball, C., Wyrzykowski, A., Kirkpatrick, A., Dente, C., Nicholas, J., Salomone, J., et al. (2010). Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Canadian Journal of Surgery , 53 (3), 184-188.

Fifth intercostal space, anterior axillary line

Jones, R., & Hollingsworth, J. (2002). Tension pneumothoraces not responding to needle thoracocentesis. Emergency Medicine Journal , 19, 176-177.

Blood and tissue can cause a blockage

Causing your own pneumothorax

Confirmed with computed tomography

- 1.3cm thinner

- Safer

- Less complications

Swine studies

Needle in the lung = pneumothorax

Jones, R., & Hollingsworth, J. (2002). Tension pneumothoraces not responding to needle thoracocentesis. Emergency Medicine Journal , 19, 176-177.

Stevens, L., Rochester, A., Busko, J., Blackwell, T., Schwartz, D., Argenta, A., et al. (2009). Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehospital Emergency Care , 13 (1), 14-17.

It's not where you think it is!

Martin, M., Satterly, S., Inaba, K., & Blair, K. (2012). Does needle thoracostomy provide adequate and effective decompression of tension pneumothorax? Trauma and Acute Care Surgery , 73 (6), 1412-1417.

- Can J Surg. 2010 Jun;53(3):184-8.

- Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7

- J Trauma. 2008 Jan;64(1):111-4

- J Trauma 2008 Oct;65(4)”:964

- Accid Emerg Med 1996;6:426–7

- Injury 1996;5:321–2.

Ferrie, E., Collum, N., & McGovern, S. (2005). The right place in the right space? Awareness of site for needle thoracocentesis . Emergency Medicine Journal , 22, 788-789.

Iatrogenic Injury

Damage to chest structures

- Internal mammary vessles

- Subclavian vessles

- Lung

- Heart

Rawlins, R., Brown, K., Carr, C., & Cameron, C. (2003). Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emergency Medicine Journal , 20, 383-384