From the Guidelines
A finger thoracostomy is performed by creating a 2-3 cm horizontal incision at the 4th or 5th intercostal space in the mid-axillary line, followed by blunt dissection and insertion of a gloved finger into the pleural space to decompress a tension pneumothorax. The procedure involves identifying the correct landmark, cleaning the area with antiseptic solution if time permits, and administering local anesthetic if the patient is conscious and time allows 1. The incision is made directly over the top of the rib, and a tract is created through the intercostal muscles just above the rib, avoiding the neurovascular bundle that runs below each rib. Once through the pleura, the gloved finger is inserted into the pleural space to confirm entry and sweep to break any adhesions, and a rush of air should be felt if a tension pneumothorax was present.
The provided evidence focuses on the diagnosis and treatment of tension pneumothorax, including the use of needle thoracentesis and tube thoracostomy 1. However, in the context of performing a finger thoracostomy, the key steps involve creating an opening in the chest wall and inserting a gloved finger into the pleural space to decompress the tension pneumothorax. The evidence highlights the importance of timely and effective treatment in saving wounded soldiers, with tension pneumothorax accounting for 3-5% of all preventable wartime injuries during the Vietnam War.
Some key points to consider when performing a finger thoracostomy include:
- Identifying the correct landmark, typically the 4th or 5th intercostal space in the mid-axillary line
- Creating a 2-3 cm horizontal incision directly over the top of the rib
- Using blunt dissection to create a tract through the intercostal muscles just above the rib
- Avoiding the neurovascular bundle that runs below each rib
- Inserting a gloved finger into the pleural space to confirm entry and sweep to break any adhesions
- Converting the opening to a formal chest tube placement if necessary.
It is essential to note that finger thoracostomy is typically performed in trauma settings or cardiac arrest situations where tension pneumothorax is suspected and needle decompression has failed or is unavailable. The anatomical approach above the rib prevents damage to the intercostal vessels and nerves that run along the inferior border of each rib.
From the Research
Procedure for Finger Thoracostomy
The procedure for performing a finger thoracostomy, also known as emergency decompression of the thoracic cavity, involves the following steps:
- Find landmarks: Identify the appropriate location for the procedure, typically the second intercostal space, midclavicular line 2
- Inject lidocaine/pain medicine: Administer local anesthesia to minimize pain and discomfort 2
- No infection allowed: Ensure a sterile environment and follow proper infection control protocols 2
- Generous incision: Make a sufficient incision to allow for insertion of the finger into the pleural space 2
- Enter pleural space: Carefully insert the finger into the pleural space to decompress the thoracic cavity 2
- Reach in with finger, sweep, reassess: Use the finger to sweep the pleural space and reassess the patient's condition 2
Advantages of Finger Thoracostomy
Finger thoracostomy has been shown to be a safe and effective alternative to traditional chest drain insertion in prehospital trauma patients 3, 4, 5
- Faster and simpler to perform than traditional chest drain insertion 3
- Avoids the risks associated with insertion of a chest drain 3
- Can be performed by trained physicians in a prehospital setting 4, 5
Comparison to Needle Thoracostomy
Finger thoracostomy may be a more effective option than needle thoracostomy, which has a significant failure rate due to the potential for the needle to not enter the pleural space 6
- Needle thoracostomy may be unsuccessful in up to 50% of patients due to chest wall thickness 6