• 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:
  • Lignocaine
  • Ketamine

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.