Anyone doing this?
Finger Thoracostomy
- Thread starter joeDO2
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It's a normal part of doing a chest tube, to stick your finger in the chest to confirm you're in the pleural space. (I'm assuming that's what you're talking about.) That's how you get the tube in there and leave no chance of being one of these people that puts the tube subcutaneous.
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I think he's talking about just the first half of the chest tube a la Scott Weingart. It's basically making an argument for not putting in the chest tube during the initial resus because it takes an extra minute or so. It's just opening the chest cavity bilaterally to take them out of play. It would save a couple minutes in the front end, but you would spend it in the back end.
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Post a link, please.
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He advocates for it in lieu of a chest dart as it would relieve the tension if it exists but would not cause a pneumothorax if there was not one (unlike the needle)...
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Besides Weingart, Jeff Hill from UCincinnati also has a good overview:
https://tamingthesru.com/finger-thoracostomy/
https://tamingthesru.com/finger-thoracostomy/
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Yes weingarts method was what I was asking about. I've heard some buzz about it lately and read about but was just wondering if anyone had put it into practice or had opinions on it since the fail rate of the needle is so high.
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And if you do a finger thoracostomy, they're going to get a chest tube anyways. I read through one of the links and they claimed an advantage of the finger vs tube thoracostomy is the reduced risk of infection because of not leaving a chest tube behind. That's an absolutely ridiculous reason to do this.
If you get a large patient, you'll not be able to keep the hole open and that could be a problem. Yes, you have risks of collapsing a lung with a needle, but the risks are far greater with a finger or tube thoracostomy.
Overall, I rate this idea poorly.
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Interesting.... This is new to me. I don't really think we have enough literature to support this as advantageous over a simple needle. If the short one isn't working, get a longer one as the article Bird posted listed. Hell, stock a few thoracic vents. I think your chances of causing more iatrogenic harm with routine finger thoracostomies are probably not insignificant. Also, you've just insured that they are likely to get a chest tube after doing this or serial repeat XR's and since it's not like you're going to stand the pt up and send him over for a PA/LAT after doing this, is anyone not going to do a CT to make sure you didn't iatrogenically cause a PTX? If you did, now you definitely need a chest tube. (If you weren't going to put one in anyway.)
I mean, if a guy comes in and I'm suspicious of a tension PTX and it's sig enough to cause him to crash, I find it really hard to believe that a big ass perc needle isn't going to decompress the guy enough to allow me to make the dx, especially combined with the PE and a stat CXR (especially nice when they have those portable monitors on them). If it's small enough for me to miss and only pick up on CT afterwards (probably just a simple PTX in that case, then I doubt he needed a finger thoracostomy in the first place or emergent decompression from a big ass tension that I just happened to completely miss but I guess all things are possible. On that note, if I'm suspicious enough to be sticking my finger through the guys chest and feeling around, chances are I'm just going to shove the tube in and be done with it, taking that variable out of the equation entirely.
I think your chances of iatrogenic complications from routine use of this method would be difficult to defend as standard of care if it came back to bite you.
I mean, if a guy comes in and I'm suspicious of a tension PTX and it's sig enough to cause him to crash, I find it really hard to believe that a big ass perc needle isn't going to decompress the guy enough to allow me to make the dx, especially combined with the PE and a stat CXR (especially nice when they have those portable monitors on them). If it's small enough for me to miss and only pick up on CT afterwards (probably just a simple PTX in that case, then I doubt he needed a finger thoracostomy in the first place or emergent decompression from a big ass tension that I just happened to completely miss but I guess all things are possible. On that note, if I'm suspicious enough to be sticking my finger through the guys chest and feeling around, chances are I'm just going to shove the tube in and be done with it, taking that variable out of the equation entirely.
I think your chances of iatrogenic complications from routine use of this method would be difficult to defend as standard of care if it came back to bite you.
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Sounds fine in theory, but only seems to make sense in a blunt trauma arrest who you're not going to do a thoracotomy on. The other case would be a peri-arrest patient with a suspected tension PTX, but in that patient they're going to need a chest tube anyway, so seems to make more sense to either just needle them or quickly do a chest tube.
The main barrier to the technique overall is that most trauma surgeons don't practice or support it, other than Karim Brohi:
http://www.trauma.org/index.php/com...pipermail/trauma-list/2004-August/021962.html
The surgeons at my hospital have no interest in this technique, and therefore it is not done. They would look at me like I was a chiropractor if we did this.
I can just picture the email chain that would ensue.
The main barrier to the technique overall is that most trauma surgeons don't practice or support it, other than Karim Brohi:
http://www.trauma.org/index.php/com...pipermail/trauma-list/2004-August/021962.html
The surgeons at my hospital have no interest in this technique, and therefore it is not done. They would look at me like I was a chiropractor if we did this.
I can just picture the email chain that would ensue.
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I'll be on the pro-side of this argument, as I do perform these occasionally, albeit in very select cases.
Each time I've done it is in traumatic arrest, generally in overweight patients in which I'm skeptical that the needles (already placed by EMS) have entered the thorax. I like the finger thoracostomy because I know for sure that I've decompressed any PTX that has existed. I'm not always convinced with the needles.
In all fairness, no patient I've done it on has survived. I agree with most of you that, in a crashing PTX patient, or in a peri-arrest patient, you might as well just complete the procedure and sew the chest tube in.
Each time I've done it is in traumatic arrest, generally in overweight patients in which I'm skeptical that the needles (already placed by EMS) have entered the thorax. I like the finger thoracostomy because I know for sure that I've decompressed any PTX that has existed. I'm not always convinced with the needles.
In all fairness, no patient I've done it on has survived. I agree with most of you that, in a crashing PTX patient, or in a peri-arrest patient, you might as well just complete the procedure and sew the chest tube in.
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The reduced risk of infection was cited as a benefit in the setting of helicopter EMS. Why is deferring a chest tube for a stationary and more hygienic environment is ridiculous if you can get away with not placing it immediately? Also, why is your assumption that a finger thoracostomy causes more iatrogenic harm than a needle thoracostomy more valid than the opposite assumption made by the pro-crowd?
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A finger or a tube thoracostomy both require instruments to be able to get into the pleural space. This is not a totally benign procedure. I've worked with people who have had first hand experience with complications where the instrument they used to go into the space ended up going into the heart and the patient died.
And to be honest, with my experience doing trauma rotations during residency, exactly zero of the patients that got needled actually needed it.
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I do finger thoracostomies, but only in mechanically ventilated patients in cardiac arrest or peri-arrest. In my experience it is much quicker than tube thoracostomy, and in a patient on positive pressure ventilation there is no rush to place the tube once you've made the hole (you don't have to restore negative pressure for their ventilation). If they survive you can place a tube afterwards if you want. In practice I've only done it on coding asthmatics, since in trauma I always have enough hands around to dedicate 1-2 residents to doing the tube thoracostomy while having enough people around to do other things.
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None of his points are convincing, and I disagree about the speed. I've led a junior resident who has never done a thoracostomy of any sort through the procedure in a coding asthmatic and it took about a minute. When I do it myself it's even quicker.
As some other have mentioned already, there isn't any data to support either side. If you think it's faster than you should do it.
