UNCONTROLLED WHEN PRINTED
Indications
Contraindications
  • Simple Pneumothorax
  • < 12 years
Patient Factors & Considerations
  • 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.
Procedure
  • 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.

  1. Fingerthoracostomy1

  2. Fingerthoracostomy2

  3. Fingerthoracostomy3

  4. Fingerthoracostomy4

  5. Fingerthoracostomy5

  6. Fingerthoracostomy6
Success
  • Reassess continuously for the redevelopment of a tension pneumothorax. Be prepared to repeat steps 7 – 10 if required.
Discontinue
Discontinue
Additional Information
Additional information

References
References

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Directorate
Clinical Services

Responsible Manager
Head of Clinical Services

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