• Tension pneumothorax/hemothorax is an immediate life-threatening condition. Emergent decompression by finger/needle thoracostomy is required to prevent respiratory and cardiovascular collapse.

• Finger/needle thoracostomy is an emergency procedure performed to alleviate a tension pneumothorax or hemothorax by inserting a large bore needle or creating an incision to access the pleural space.
• Both needle thoracostomy and finger thoracostomy have similar patient outcomes.
• Needle thoracostomy has been traditionally recommended over finger thoracostomy, although care must be taken to ensure adequate needle length and proper technique to avoid failure.
• Finger thoracostomy, also known as simple thoracostomy, allows for direct confirmation the pleural space has been accessed and allows the clinician to simultaneously manage hemothorax with the insertion of a chest tube.
• Ultimately, patients who have a tension pneumothorax or hemothorax that is decompressed will require a definitive tube thoracostomy.

The clinical presentation and diagnosis of tension pneumothorax can be reviewed here: https://emergencycarebc.ca/clinical_resource/tension-pneumothorax/

Indications for emergent thoracostomy:

• Pneumothorax or hemothorax, with deteriorating vital signs, significantly reduced cardiac output, profound shock, or cardiac arrest.
• Bilateral decompression is indicated in cases of blunt traumatic cardiac arrest.

Contraindications to emergent thoracostomy:

• No absolute contraindications in an unstable patient.

• PPE as appropriate.
• Anti-septic solution (i.e., povidone-iodine, chlorhexidine).
• Sterile gloves.
• Large bore angiocatheter – A 14-gauge needle is recommended. 8-cm needles are more successful than 5-cm but increase the risk of inadvertent injury to underlying structures. Longer needles may be required in patients with significant chest wall thickness. Caution: Some newer angiocatheters may have a blood control valve in them which will not allow release of the tension pneumothorax. If you have one of these you can permanently open the valve by attaching a syringe to and removing the syringe from the angiocatheter before you do the procedure.

If providing local anesthetic (depending on clinical context):

• 10 to 20 mL syringes and various needle sizes (for local anesthetic)
• Local anesthetic

Needle Thoracostomy Procedure:

• Use standard procedures for PPE and sterile technique.
• When patient is competent/accompanied by a substitute decision maker, obtain informed consent. Otherwise, proceed under implied consent.
• Place the patient supine, with the arm on the affected side abducted and externally rotated. Place the patient’s hand behind their head.
• Landmark: Traditionally, the anterior approach (insertion in the 2^nd intercostal space in the mid-clavicular line) was standard practice. Due to growing evidence of failure and associated complications, the lateral approach is now recommended (insertion at the 5^th intercostal space along the mid to anterior axillary line). An exception is made in obese patients, where the lateral chest wall is likely too thick for needle decompression.
• Disinfect the skin.
• Consider injecting local anesthetic above the superior aspect of the inferior rib depending on the clinical context.
• Remove the angiocatheter from its packaging. A 14-gauge is preferred over 16-gauge. A shorter (2.5 inches) needle can be considered in patients with a suspected thinner chest wall.
• Puncture the skin and direct the needle slightly above the inferior rib, of the selected interspace, to avoid neurovascular structures on the inferior border of the superior rib. Air may be heard as the needle enters the pleural space.
• Advance the catheter into the pleural space. Remove the needle.
• Leave the catheter open to air.
• Reassess the patient for signs of pressure release.
• If the first attempt fails, use ultrasound to measure chest-wall thickness to determine the appropriate needle length.

Finger Thoracostomy Materials:

• PPE as appropriate
• Anti-septic solution (i.e., povidone-iodine, chlorhexidine)
• Sterile drapes
• Sterile gloves
• Scalpel with No. 10 blade
• Large Kelly clamp

If providing local anesthetic (depending on clinical context):

• 10 to 20 mL syringes and various needle sizes (for local anesthetic)
• Local anesthetic

Finger Thoracostomy Procedure:

• Use standard procedures for PPE and sterile technique.
• When patient is competent/accompanied by a substitute decision maker, obtain informed consent. Otherwise, proceed under implied consent.
• Place the patient supine, with the arm of the affected side abducted and externally rotated. Place the patient’s hand behind their head.
• Landmark: Identify the 4^th or 5^th intercostal space in the mid to anterior axillary line (this is just cranial to the inframammary fold). An incision will be made between the midaxillary line and the anterior axillary line.
• Disinfect the skin.
• Consider parenteral analgesics or sedation or injecting local anesthetic above the superior aspect of the inferior rib, depending on the clinical context.
• Using a scalpel with a No. 10 blade, make a 4-5 cm incision parallel to the inferior rib between the midaxillary line and the anterior axillary line. Ensure the incision is sufficient to create an adequate tract.
• Use a large Kelly clamp to bluntly dissect through the intercostal muscles. Firm resistance will be felt at the parietal pleura. With a closed clamp, held firmly close to the patient’s chest wall to prevent deep penetration, forward pressure is applied until the chest cavity is entered. A pop may be heard when the chest cavity is reached. Spread the forceps to open the space. Make the opening wide enough to comfortably insert both a finger and a chest tube. Remove the forceps.
• Insert a gloved finger and sweep to ensure the pleural space has been accessed.
• Continue to sweep and assess for the release of air or blood.

The FINGER pneumonic can be useful:

• Find landmarks.
• Inject pain medication.
• No infection allowed.
• Generous incision.
• Enter pleural space.
• Reach in with finger, sweep, reassess.

Complications:

• Ineffective decompression.
• Angiocatheter can become dislodged, blocked with blood clot or kinked.
• Pneumothorax (if tension pneumothorax was falsely suspected).
• Infection.
• Damage to neurovascular bundle resulting in bleeding or nerve injury.
• Pulmonary laceration.
• Other organ damage (cardiac, diaphragm, liver).

Chest Tube Placement:

• All patients undergoing decompression require definitive management of their pneumothorax/hemothorax with a chest tube.
  • Small bore indications (14 Fr recommended): spontaneous pneumothorax post needle decompression.
  • Large bore indications (28-32 Fr recommended): penetrating injuries, traumatic hemothorax, patients on mechanical ventilation, patient who underwent finger thoracostomy.
• A chest radiograph must be performed to confirm chest tube placement.

Access the full procedure for chest tube placement here: https://emergencycarebc.ca/clinical_resource/chest-tube-placement/ 

1. Needle thoracostomy and finger thoracostomy demonstration videos: https://first10em.com/videos/thoracics-videos/#NEEDLE-1

   Clinical resource on finger thoracostomy:

   https://clinical.stjohnwa.com.au/clinical-skills/trauma/finger-thoracostomy

    

   
   

1. Fowler GC. Pfenninger & Fowler’s procedures for primary care. 4th ed. Philadelphia, Pa: Elsevier; 2020. Chapter 211, Tube Thoracostomy and Emergency Needle Decompression of Tension Pneumothorax; p. 1394-1400.

   
   

2. Harris CT, Taghavi S, Bird E, Duchesne J, Jacome T, Tatum D. Prehospital Simple Thoracostomy Does Not Improve Patient Outcomes Compared to Needle Thoracostomy in Severely Injured Trauma Patients. The American SurgeonTM [Internet]. 2023 May 10;89(5):1736–43. Available from:

   http://journals.sagepub.com/doi/10.1177/00031348221075746

   
   

3. Merelman A, Zink N, Fisher AD, Lauria M, Braude D. FINGER: A Novel Approach to Teaching Simple Thoracostomy. Air Medical Journal. 2022;41(6).

   
   

4. Reuben. Your new angiocath will not relieve tension pneumothorax [Internet]. Emergency Medicine Updates. 2016. Available from:

   https://emupdates.com/your-new-angiocath-will-not-relieve-tension-pneumothorax/

   
   

5. Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7^th ed. Philadelphia, Pa: Elsevier; 2019. Chapter 10, Tube Thoracostomy; p. 196-220.