Critical Care Paramedicine Podcast

Episode 10: My Finger: Coming to a Pleural Space Near You?

Needle chest decompression has long been the standard of prehospital care. But what if we can do better? Klint Kloepping, Flight Paramedic from Nebraska, joins us for a discussion on finger thoracostomy.

For those not familiar, a finger thoracostomy is performed by taking a scalpel to the tissues at the 5th rib at the midaxillary and bluntly dissecting down to the pleural space with a finger or, sometimes, a pair of hemostats or clamps.

The issues surrounding standard needle thoracostomy for decompression and several fold. Many agencies do not have a special, dedicated extra-length angiocatheter for needle decompression. In a study the standard 4.6 cm angiocatheter was found to be long enough to reach the pleural space in only 52.7% of patients when done at the 2nd intercostal space, midclavicular line. In some cases, this location has also been shown to result in life threatening hemorrhage from lacerating the subclavian vessels, internal mammary artery and its medial branches. You know what really helps your patient with a life threatening pneumothorax? An iatrogenic life threatening hemothorax on top of it.

The lateral or midaxillary position is not free from risk an adverse effects either. Using a proper 8 cm chest decompression needle (such as the Cook Pneumothorax Kit), providers have a significantly increased the risk of damaging the left ventricle, when using a left midaxillary approach. When you look at it, it’s a wonder that we considered plunging a long needle into the chest without knowing the underlying anatomy a good idea at all.

Show Notes

  • Guest discussion with Klint Kloepping
  • FlightBridgeED
  • Second Shift Podcast
  • EMCrit: Podcast 62 – Needle vs. Knife II: Needle Thoracostomy?
  • Carter TE, et al. Needle Decompression in Appalachia Do Obese Patients Need Longer Needles? West J Emerg Med, 2013; 14(6): 650–2.
  • Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J, 2005 Nov; 22(11): 788–9.
  • Rawlins R, et al. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J, 2003 Jul; 20(4): 383–4.
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