Needle Thoracostomy is a bad move!
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
Updates
See these observations from the military
Additional New Information
More on EMCrit
EMCrit 313 – Tube Thoracostomy (Chest Tubes) Part 2(Opens in a new browser tab)
EMCrit Podcast 16 – Coding Asthmatic, DOPES and Finger Thoracostomy(Opens in a new browser tab)
EMCrit 245 – Tension Pneumothorax with Simon Leigh-Smith(Opens in a new browser tab)
EMCrit 255 – Pigtails for Pleural Problems (Percutaneous Thoracostomy)(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Podcast 62 – Needle vs. Knife Part II, finger thoracostomy vs. needle decomp!Let me know your thoughts @Skepticscalpel. http://t.co/tU9JXx0L
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)
Can’t see any reason it would mess up the chest tube.
“The Tradition of Care” strikes again! If the ThoraQuik weren’t 10 times the price of a angiocath, I’d see about getting it on the truck.
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
Not a big trocar fan, when sharp they are dangerous, when blunt they would be too big to penetrate muscle. They were fun to threaten lazy interns with though.
Or use to grow tomatoes (make great vertical posts)
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,… Read more »
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.
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… Read more »
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.
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. 🙂
FIXED!!!! Much thanks to Adrian. That is 4th/5th Mid-Ax line!!!
Damn, too late – I wondered where all that blood was coming from!
thats a very good reason to use USS before the knife!
Excellent discussion. Hopefully someday paramedics will have an option to do something other then needle thoracostomies.
There’s serious discussion of it being incorporated into our statewide EMS protocols (Vermont).
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?
Usually mine are “smoking the blue cigar” (intubated and ventilated) by the time they score a finger thoracostomy. Or moribund (tamponade from bilateral PTXs).
Hi Scott,
Thanks for the great Podcast.
Is there any evidence or study to support that finger thoracostomy is better than needle?
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… Read more »
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… Read more »
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.
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?
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… Read more »
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.
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… Read more »
I don’t mean to hijack, but ran into a question regarding this today in a trauma arrest we got back after opening his left chest and finger thoracostomy to right. He was intubated and on positive pressure about the same time. Is there any data or guideline (or even just your expert opinion) regarding how long you can go before needing to then place a chest tube on that side after simple finger thoracostomy? I wound up getting a lot of grief from the trauma resident regarding my lack of a chest tube – my thought process was that there… Read more »
Sorry to join late. I still think needle has a role: Finger thoracostomy is fine in arrest but for deteriorating patient time consuming and potentially needless injury if not pneumo as cause. Certainly till paramedics can do it the safest way to do needle decompression matters. See my article ‘The hanging-drop to locate the pleural space: a safer method for decompression of suspected tension pneumothorax? J Trauma. 2010 Oct;69(4):970-1. I think it is an interesting read, though ignored so far by others! Would welcome feedback.
Sorry. In my comment i failed to give my job etc. I’m a consultant anaesthetist in England, and a military reservist. I’ve done pre-hospital helicopter work in Afghanistan.
I am working as a prehospital emergency doctor in Germany. If I understand correctly than that finger thoracostomy could be a rapid intervention to rule out or even treat tension-pneumothorax in the arrest or near arrest trauma-patient. What I do not quite understand is why pneumothorax is not mentionned as a possible unwanted effect of finger thoracostomy? Could I not make the patient worse in case his pre-arrest is not due to pneumothjorax or tension pneumothorax, by creating a pneumothorax – especially if I do it before Intubation?
the only pneumothorax you can cause is air entraining into the chest cavity, this is a clinically irrelevant amount of air. it is impossible for this to tension as there is no pressurized source of gas.
In this arrest situation do we have time to gown up?
nope
just out of curiosity does anyone have any experience with the use of a thoracic vent? such as the uresil tru close vent or the rocket pleural vent. if so how are they compared to other methods of treating pneumothorax? in a pinch could it effect a hemothorax?
any insight would be appreciated. thanks.