From the Guidelines
Finger thoracostomy in Australia should be performed in patients with tension pneumothorax or significant traumatic chest injuries when immediate decompression is required, as it provides a higher success rate and lower risk of failure compared to needle decompression 1.
Indications for Finger Thoracostomy
The procedure is typically indicated in the pre-hospital or emergency setting for patients with:
- Tension pneumothorax
- Significant traumatic chest injuries
- Clinical signs of tension pneumothorax, such as decreased breath sounds, hypotension, respiratory distress, and tracheal deviation, combined with deteriorating vital signs
Procedure and Protocol
The procedure involves making an incision in the 4th or 5th intercostal space, mid-axillary line, followed by blunt dissection through the pleura and insertion of a finger to create a pathway for air release. This is generally performed by advanced paramedics, emergency physicians, or critical care providers with appropriate training. In Australia, many ambulance services and retrieval teams have protocols allowing finger thoracostomy rather than needle decompression as the preferred emergency intervention for tension pneumothorax.
Post-Procedure Care
The procedure should be followed by formal chest tube insertion when the patient reaches definitive care. The advantage of finger thoracostomy over needle decompression is the higher success rate, lower risk of failure, and creation of a definitive pathway that won't easily occlude, making it particularly valuable in the Australian context where transport times to definitive care may be extended 1.
Key Considerations
- Retained hemothorax is a risk factor for developing pneumonia and empyema, and tube thoracostomy can help reduce this risk 1
- Presumptive antibiotic use in thoracostomy has a clear role in preventing infectious complications in chest trauma patients, particularly in penetrating injuries 1
From the Research
Indications for Finger Thoracostomy
- Tension pneumothorax, a life-threatening condition encountered mainly in trauma and critical care environments 2
- Traumatic cardiac arrest, tension pneumothorax, and massive haemothorax in children, as thoracostomy is an effective and reliable method to achieve emergency pleural decompression 3
- Chest trauma, as finger thoracostomy is frequently performed by intensive care flight paramedics and is associated with a low rate of major complications 4
Timing of Finger Thoracostomy
- As soon as possible in the prehospital setting, as it is a valuable adjunct in the management of tension pneumothorax 2
- After needle decompression, as most patients require tube thoracostomy after needle decompression of the chest 5
- In the emergency department, as thoracostomy is recommended as soon as practicable after thoracic decompression 6
Considerations for Finger Thoracostomy
- Potential complications, such as recurrent tension physiology, which is more frequent in finger compared with tube thoracostomy 6
- Technical challenges, particularly in children, but these can be addressed by training to support a low complication rate 3
- The need for subsequent tube thoracostomy, as most patients require it after needle decompression of the chest 5