- To decompress a suspected tension pneumothorax
- Simple Pneumothorax
- < 12 years
- The potential for exposure to blood and body fluids is HIGH. All precautions that serve to minimise risk to the clinician and the patient are to be applied.
- Clinicians should be double-gloved with sterile gloves on the outside.
- In traumatic cardiac arrest, finger thoracostomy should be performed bilaterally, starting on the side with the suspected tension pneumothorax.
- If patient is conscious, perform procedure on affected side only.
- There is significant risk of injury to the clinician in case of chest trauma where rib fractures may occur. Extreme caution to be taken when inserting finger into the tract.
- Incorrect placement may result in life threatening injuries to the heart, lung or surrounding vessels.
- All relevant infection control methods are to be utilized.
- Prepare equipment required:
- Underpad / bluey
- Sterile kidney dish
- Necessary PPE including sterile gloves; double glove
- Disposable Scalpel
- Face shield for clinician and assistant
- Povidone-Iodine Swabs
- Ferno Sam Chest Seal
- Sterile gauze
- Haemostatic Forceps
- Consider appropriate analgesia for the conscious patient:
Patient positioning
- The patient should ideally be positioned supine, alternatively in the most comfortable position.
- The arm on the affected side should be abducted and externally rotated, simulating a position in which the palm of the hand is behind the patient’s head.
- An underpad / bluey should be placed under the side where the finger thoracostomy is to take place to absorb draining bodily fluids.
Patient preparation
- Position the patient as described above, identifying the ‘triangle of safety’ as shown[1]
- Identify the fifth intercostal and the midaxillary line on affected side:
- The skin incision is made in between the midaxillary and anterior axillary lines over a rib that is below the intercostal level selected
- Shave excessive hair and clean a wide area of the chest wall area with Povidone-Iodine Swab[2]
- Administer analgesia (conscious patient):
- Use a needle to inject 50-100mg (5-10mL) of the local anaesthetic solution into the intercostal muscle superior to the expected initial incision.
- Administer ketamine for procedural sedation (unless contraindicated or patient unconscious)
Performing the procedure
- Use the scalpel to make a horizontal skin incision adequate size for the insertion of finger (approximately 4 – 5cm long) overlying the rib that is below the desired intercostal level of entry. The skin incision should be in the same direction as the rib itself[3]
- Dispose of the used scalpel immediately into the sterile kidney dish
- Use the haemostatic forceps to bluntly dissect a tract in the intercostal space.
- Anchoring the forceps with your index finger at a depth estimated to enter the pleural space; used the closed forceps to bluntly dissect a tract through the intercostal muscles and parietal pleura and enter into the pleural space as shown[4].
- This manoeuvre may require some force and should be done in a controlled fashion so the instrument does not enter too far into the chest, which could injure the lung or diaphragm. Use a twisting motion of the tip of the closed forceps to open and enter the pleural space. The "give" of the parietal pleura indicates access to the pleural space.
- Remove the forceps.
- Insert your full gloved finger into the space and perform a finger sweep to ensure access to the pleural space[5].
- Assess for the release of air and/or blood. You may also be able to palpate the lung parenchyma and detect lung inflation/deflation, especially if patient is receiving positive pressure ventilation
(i.e. intubated). - Apply the seal over the incision and ensure seal adequately placed[6].
- Reassess continuously for the redevelopment of a tension pneumothorax. Be prepared to repeat steps 7 – 10 if required.
- Reassess continuously for the redevelopment of a tension pneumothorax. Be prepared to repeat steps 7 – 10 if required.
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