MD1 Response: Finger Thoracostomy

MD1 Response is a recurring update on interesting out-of-hospital cases experienced by on-scene EMS physicians. Submit your cases to md1admin@md1program.org.

A 50-year-old male was crossing the street when he was struck by a motor vehicle and thrown approximately 20 feet. The speed of the car was unknown, but the maximum speed limit of the street was 45 miles an hour. A BLS crew loaded the patient after finding him prone on the street, cold, and unconscious. Paramedics arrived on scene and found the patient shivering and responsive to painful stimuli with a GCS score of 8 (E1, V2, M5). The paramedics’ physical examination was remarkable for abdominal tenderness and guarding. Initial vital signs were blood pressure 110/palp., heart rate 108 bpm, respiratory rate 24, and oxygen saturation 76% on room air.

EMS physician MD27 arrived on scene to find the patient on supplemental oxygen via nonrebreather with underlying nasal cannula. MD27 assessed the patient and found a GCS of 7 (E1, V1, M5) and a soft, nontender abdomen with no guarding. Portable ultrasound showed no pericardial effusion, no intraperitoneal free fluid, lung sliding on the right anterior and lateral lung with scattered B-lines, and lung sliding on the left lateral lung. On the left anterior chest, MD27 visualized a lung point approximately one rib large. A lung point sign that shows lung sliding on one side and not the other is highly specific for a pneumothorax. Repeat vital signs were BP 172/118, HR 113, RR 8 with bag-valve mask ventilation (BVM), and oxygen saturation 94%. After a few breaths with the BVM, oxygen saturation increased to 99%.

MD27 performed a finger thoracostomy to release the pneumothorax and prevent a tension pneumothorax, which can form as a result of mechanical ventilation and/or changes in barometric pressure from altitude during helicopter transport. The area was cleaned with chlorhexidine, and the physician made a 3–4-cm transverse incision over the left lateral chest in the vicinity of the fifth intercostal space in the midaxillary line. He inserted a sterile gloved finger to feel the parietal pleura to ensure entering the thorax. Air was noted to release, and there was no significant drainage of blood during the procedure. The incision was dressed to allow air to escape the chest but not enter via the site. The patient was intubated via RSI protocol with ketamine and fentanyl, then packaged and transferred to the helicopter for transport to the nearest Level 1 trauma center.

Prehospital thoracostomy interventions include needle, blunt (finger), or tube thoracostomy. Few prehospital transport crews have developed protocols for simple thoracostomy in blunt-trauma victims. Indications for simple thoracostomy in the prehospital setting include pneumothorax in a patient undergoing positive-pressure ventilation (diagnosed or high-risk), unexplained hypoxia or hypotension in a ventilated patient, or traumatic cardiac arrest or periarrest state.¹ Indications for finger or tube thoracostomy include traumatic arrest, shock with suspicious or unknown cause, shock or low cardiac output with evidence of thoracic/abdominal trauma, or shock or low cardiac output with positive-pressure ventilation.² The main difference is that the former includes high-risk patients whose injuries may lead to tension pneumothorax.

We could not find evidence of infections related to prehospital finger thoracostomy. There were two studies that looked at prehospital tube thoracostomy vs. in-hospital tube thoracostomy, and neither found significant differences in infection rates. Aggressive prehospital management can reduce mortality with low associated morbidity.^3–7

Finger thoracostomy is a safe and effective solution for tension pneumothorax for EMS physicians. Pneumothorax is difficult to discern on physical examination, and classic findings occur late with poor outcomes if they are not recognized. With the expertise and availability of portable ultrasound, EMS physicians can capture a pneumothorax and provide early intervention. For this patient pneumothorax was detected early, and tension pneumothorax avoided.

References

1. Chesters A, Davies G, Wilson A. Four years of pre-hospital simple thoracostomy performed by a physician-paramedic helicopter emergency medical service team: A description and review of practice. Trauma, 2016; 18(2): 124–8.

2. High K, Brywczynski J, Guillamondegui O. Safety and efficacy of thoracostomy in the air medical environment. Air Med J, 2016 Jul–Aug; 35(4): 227–30.

3. Schmidt U, Stalp M, Gerich T, Blauth M, Maull KI, Tscherne H. Chest tube decompression of blunt chest injuries by physicians in the field: effectiveness and complications. J Trauma, 1998 Jan; 44(1): 98–101.

4. Spanjersberg WR, Ringburg AN, Bergs EA, Krijen P, Schipper IB. Prehospital chest tube thoracostomy: effective treatment or additional trauma? J Trauma, 2005 Jul; 59(1): 96–101.

5. Perkins Z, Gunning M. Life-saving or life-threatening? Prehospital thoracostomy for thoracic trauma. Emerg Med J, 2007 Apr; 24(4): 305–6.

6. Massarutti D, Trillo G, Berlot G, et al. Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews. Eur J Emerg Med, 2006 Oct; 13(5): 276–80.

7. Pritchard J, Hogg K. BET 2: Pre-hospital finger thoracostomy in patients with chest trauma. Emerg Med J, 2017 Jun; 34(6): 419.

Jeffrey Uribe, MD, is an EMS and disaster medicine fellow at RWJBarnabas Health’s Newark Beth Israel Medical Center in Newark, N.J., as well as an emergency medicine attending physician with Envision Physician Services.

Navin Ariyaprakai, MD, EMT-P, FAEMS, FACEP, is EMS physician for the MD1 program, program director for the EMS and disaster medicine fellowship at Newark Beth Israel, and core faculty for the emergency medicine residency at Newark Beth Israel.

Ammundeep Tagore, MD, MSHA, MBA, FAAEM, FACEP, is associate program director of the EMS and disaster medicine fellowship and core faculty of the emergency medicine residency at Newark Beth Israel Medical Center, as well as serving as a physician and on the board of directors for MD1.

Josephine V. Geranio, BS, is administrative assistant to Mark Merlin and the MD1 team and continues to work in the ED.