Podcast 62 – Needle vs. Knife II: Needle Thoracostomy?

Needle vs. Knife Part II

In this podcast, I explain why I don’t think needle compression is such a clever idea. Main points are: most people can’t find anterior target, most angiocaths won’t reach, and if used diagnostically you may not be in the pleura leading to an unidentified pneumo or hemothorax. Also, when used diagnostically, if the chest was negative you just caused a pneumothorax.

If you haven’t already, you should listen to Needle vs. Knife Part I with Minh. Also, may of the issues discussed here are also mentioned in the finger thoracostomy episode and the traumatic arrest episode.

Why the standard approach to needle decompression sucks

Normal IV catheters do not reach in up to 65% of the cases

Can J Surg. 2010 Jun;53(3):184-8.

Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7

J Trauma. 2008 Jan;64(1):111-4

J Trauma 2008 Oct;65(4)”:964

Accid Emerg Med 1996;6:426–7

Injury 1996;5:321–2.

Brand New Study state failure in 42% of cases (Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax Arch Surg. 2012 Sep 1;147(9):813-8)

 

Anterior Approach is not Where You Think it is

Emerg Med J 2003;20:383-384

ED Docs got it wrong a lot! (Emerg Med J 2005;22:788)

Use the Lateral Approach if you are going to do Needle Thoracostomy

ANZ J Surg. 2004 Jun;74(6):420-3

Study says Anterior is closer, but (smooth concept here) the patients had their arms in the air

(Acad Emerg Med 2011;18:1022)

Even if you get it right, Cannula may kink, occlude, or compress

Emerg Med J 2002;19:176-177

Traumatic Arrest is not Dismal until Tension Pneumo is Ruled Out

Emerg Med J. 2009 Oct;26(10):738-4

This device makes much more sense to me

Evaluation of ThoraQuik: a new device for the treatment of pneumothorax and pleural effusion (Emerg Med J 2011;28:750-753)

Michelle Lin did a great blog post about the stuff in this podcast on her Academic Life in EM Blog.

Update:

Hot off the press is this swine simulation demonstrating that even when a 14G catheter reached, it may not be sufficient to drain a tension pneumo (Journal of Trauma and Acute Care SurgeryIssue: Volume 73(6), December 2012, p 1410–1415)

A Video Demonstrating Finger Thoracostomy by Cliff Reid

Additional References

Deakin, C., Davies, G., & Wilson, A. (1995) Simple thoracostomy avoids chest drain insertion in prehospital trauma. The Journal of Trauma: Injury, Infection, and Critical Care. 39(2). 373-374.

Masarutti, D., Trillo, G., Berlot, G., Tomasini, A., Bacer, B., D’Orlando, L., Viviani, M., Rinaldi, A., Babuin, A., Burato, L., & Carchietti, E. (2006) Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews. European Journal of Emergency Medicine. 13. 276-280

Want a recorded lecture on the topic?

Michael McGonigal had me to his Trauma Conference for this lecture on the finger

Now on to the Podcast…

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Comments

  1. EMS folklore/tradition cautions against the lateral approach as it “messes up the chest tube.” Any reason to keep believing this?

    (side note: we’re using >3.25″ 14ga’s now)

  2. Hi Scott
    Nice explanation, crystallized my practice.

    We have a suture kit with a 15 disposable blade, small curved haemostat and swabs, scissors. It seems ideal for what you describe. Just add betadine!

    The old chest tubes with the sharp trocar? If they made a blunt pointed trocar – would it be ideal? You could cut then push in one motion, slide the catheter off if you get a gush?
    Casey

  3. Daniel J. Case MD says:

    Excellent short episode. I had never thought specifically of finger thoracostomy, other than to recognize that if there is a tension PTX, the issue is relieved nearly instantly once anything — and it usually is a (gloved) finger — penetrates the pleura.

    One question I would ask, though, would be the incidence objectively of not needing a chest tube later if the finger technique is negative for tension vs. using the standard needle thoracostomy approach. Have any studies looked at this? If it is as Scott says, much less likely for the finger to cause a PTX than the needle, then, hands down, we should all use this technique. How about it’s potential use in other situations, eg, a spontaneous PTX in a non-crashing patient?

    • Have not seen evidence on negative finger thoracostomy not needing a chest tube, but this is identical to the situation we have when we pull a chest tube. Exactly the same in eveyr regard except in most cases, when we pull the CT, we just put on an occlusive dressing and let the wound heal by secondary, here you can actually stitch the skin.

      For spont. pneumo in a non-crashing patient, I think aspiration, percutaneous chest tube placement (the subject of needle vs. knife 3), or the commercial devices like thoraquick are the way to go.

  4. Minh Le Cong says:

    thanks Scott
    I support most of what you advocate. I still think needle decompression has a limited role. The key issue as you highlight is diagnosis and confirmation of the problem and the resolution.
    In my practice I use portable USS heavily for diagnosis and confirmation for pneumothorax and decompression. If you need to know the depth to the pleura and the best location to decompress, you can quickly do that with USS. you need to diagnose it, use USS. once you know all those things , needle or knife, its a matter of personal choice. Spont pneumo , I would not normally use finger thoracostomy..you are essentially creating an open pneumo that will suck with negative thoracic pressure. In the ventilated patient, The finger thoracostomy is a nice technique as there is no risk of sucking open pneumo. there is still a risk of repeat tension but that is not a big deal as you can always stick the finger back into the hole and reopen it, or insert an ICC

    • Agree, if you are savvy with ultrasound–go for it. I will say when the patient is crashing, i consistently reach for a knife and not a probe. Bilat fingers touching lung and thos hemithoraces are GONE from the differential. If you feel the same way about your ultrasound, then good on you. I am an RDMS (USA speak for ultrasound geek) and I still don’t trust it enough to stake my patient’s life on. I know most of the ultrasound guys would feel confident enough and then I think it is fine to avoid the cut.

  5. Hi Scott,

    Great podcast!

    @04:30 of this podcast you say the landmarks for chest tube are 4/5th intercostal space mid*clavicular* line… Did you mean midaxillary?! That puts you straight over the heart on the left, which is probably best avoided. :)

  6. Corky Kimbrel says:

    Excellent discussion. Hopefully someday paramedics will have an option to do something other then needle thoracostomies.

  7. Josh Guttman says:

    Great talk. I was wondering about anasthesia in the finger thoracostomy technique. With a needle, little to no local anasthesia is used, whereas in conventional chest tube placement, a fair amount of local anasthesia is needed. How do the patients tolerate the finger thoracostomy with presumably not much local anasthesia, given the little time you have to get it done in the crashing patient?

  8. Usually mine are “smoking the blue cigar” (intubated and ventilated) by the time they score a finger thoracostomy. Or moribund (tamponade from bilateral PTXs).

  9. Hi Scott,
    Thanks for the great Podcast.
    Is there any evidence or study to support that finger thoracostomy is better than needle?

  10. James DuCanto, M.D. says:

    Hi Scott, et. al., and happy new year!

    The 18 gauge thin walled needle from a vascular introducer kit worked very well for me (n=1) when I totally popped a patient’s lung during subclavian approach during my (surgical) internship (patient had fractured thoracic cage due to chief complaint of Pickup Truck parked on sternum). Just food for thought–it has the rigidity and length to do the job. Over the top of the rib and away you go. I was taught a surgical approach to this procedure (chest tube insertion): Incise onto the flat portion of your chosen rib, then hemostat placed deliberately to the periosteum of that rib, and then bluntly push said hemostat over the top of chosen rib. Pop, expand hemostat, slide in the hose. Works. I was forced to do it on a 2 month old once. Same sequence, just smaller movements (that was 20 years ago).

    Thanks!

    Jim

  11. Peter Weimersheimer says:

    Scott,

    Couldn’t agree more that finger thoracostomy is a better choice for managing a tension pnuemo. However, it’s faster and much less painful to the patient to not switch from the scalpel used for the initial incision to a Kelly. I make my incision over a rib and once I’ve visualized that landmark, continue to use my scalpel immediately above the rib and am in within the time I would take to reach for the Kelly. I then use my finger to spread the hole adequately for a chest tube and confirm pleural space. It doesn’t make sense to exchange the sharp, rapidly cutting tool that I already have in my hand for a blunt one to brute my way through tissue and periostium. Works great for both crash and “elective” tubes.

    • Peter, To be honest, I have often done the same, but if I advocate that technique in a public forum someone is going to do evil. If you know what you are doing, you can nick through some of the intercostals and then use your finger for all the rest. In inexperienced hands of course, the kelly is orders of magnitude safer.

  12. I think the finger thoracostomy is obviously the way to go. Has anyone seen this written up anywhere even as a case report? Anyone lobbying to have it in the next addition of ATLS?

    • you can find a few articles on the resus.me site or just search for HEMS finger thoracostomy

      • Thanks, Cliff’s references are good, but my trauma dudes are going to reply “that’s in a helicopter” this is such an obvious topic for some bight resident to prospectively research in either the sim-lab or in the trauma bay. Who is going to volunteer?

        • SAMGHALI says:

          HeyScott!
          Re-visited this topic bc it came up in lectures the other day. Totally with you on Finger>Needle for all the reasons you mentioned. I do have one, small point of question that I thought of: in that rare instance where you just gotta do a needle for whatever reason, the question becomes anterior vs lateral decompression. In the scenario where we have a definite, confirmed pneumothorax with tension that needs decompression, we sorta assume that as long as there’s definitely a pneumo there, that it’s now fine to stick a needle in bc there is air between the visceral and parietal pleuras, and we now have a “safe zone” to protect against lung injury. But we all know how pneumos layer out and are anti-gravitational- we see this on supine CT Chests all the time, with the pneumo always anterior. My concern regarding the lateral approach is that: what if lung is attached @ that specific spot, and we are now poking the lung and causing an injury that in and of itself would have caused a pneumothorax to begin with. (Same issue with lateral pigtail) We have now compounded the pneumothorax. Another argument may be that this patient will get a chest tube regardless, so who cares if we pop the lung in another spot. But again- compounding the pneumo. The question is: does this have any significant effect on patient’s clinical course? (IE: will the chest tube have to stay in longer, will there be consequences down the road from the injured lung spot, etc..) I don’t know the answer to that question. If it turns out that it actually does matter, that might be a reason for anterior> lateral. I guess you could always check for lung sliding at that lateral spot, but the scenario where you’re choosing needle > knife, you probably don’t have that luxury. Perhaps you could also turn the pt on opposite lateral decubitus. Overall, needle is just so problematic– I think needle decompression is dead!

          Sam

          • no reason to think adhesions would be more likely lateral rather than anterior. If the pt has prior operations/procedures on that hemithorax, even more reason to use your finger. I don’t see any advantage to anterior.

            • SAMGHALI says:

              I didn’t mean adhesions– but simply lung acutely being up or down at that exact spot. The lung may be down anteriorly, but up laterally (and posteriorly). Again, I think needle decompression is basically dead, but for whatever scenario(or for whatever reason), if needle is chosen over finger, lateral approach may have higher chance of injuring lung in the supine patient, since the pneumo is anterior providing an air buffer zone. To illustrate my point: those pneumos you pick up on ultrasound by assessing anterior chest lung sliding, that the CT ultimately shows that small, inconsequential pneumo (which is obviously anterior since the pt is supine in the scanner). I realize you’re not okaying needle except for in that rare scenario where you have already seen it radiographically- and I would suspect that in a true tension pneumo, the lung should be clear even in that lateral more supine approach. But for the needlephiliac who insists on needle decompression, correctly diagnosing a pneumo but being wrong about the tension, would lead to this scenario. This may also be true for the elective pigtail where the pneumothorax is seen on x-ray and is deemed large enough to require the tube, but not large enough to separate the pleuras at that lateral position.

Trackbacks

  1. [...] be using that needle after all… Listen to Scott Weingart’s take on this in Needle versus Knife II: Needle vs. Finger Thoracostomy.Intercostal catheter insertionNow it’s time for the chest tube. Here’s Michael McGonigal again [...]

  2. [...] a knife for immediate decompression of a tension pneumothorax? Check out the discussion on EMCrit: Needle versus Knife II: Needle vs. Finger Thoracostomy.Q4. Describe how you would recognize and manage an open pneumothoraxAnswer and [...]

  3. [...] – Needle versus knife for chest decompression, podcast by Scott Weingart HERE (or click HERE for full show notes and [...]

  4. […] A sudden decline in BP or raised airway pressures in the ventilated patient should alert you to possibility of a tension pneumothorax. A needle decompression won’t cut it. In ventilated patients, be familiar with the technique of finger thoracostomy. […]

  5. […] EmCrit‘s Scott Weingart on the emergent treatment of TnPx In his 2 part podcast “Needle vs Knife” Part 1 and Part 2 […]

  6. […] Here is the associated link to Scott Weingart’s EMCrit podcast “needle vs knife” […]

  7. […] Alternative is finger thoracostomy –  If the patient is intubated & ventilated you can leave it open, but a chest drain must be inserted in a spontaneously breathing patient to avoid open pneumonthorax. You can see a couple of articles and videos on the technique here and here. […]

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