hey guys my name is Sam and welcome to pratic this week's video I'm going to show you how to do a finger Thor costum so before we get started a couple quick things number one always follow local policies procedures and laws before performing a medical intervention I promise you this is not covered by Good Samaritan laws and if you start cutting on a random motorist on the side of the road you're are going to be in a world of hurt number two the views expressed in this video do not necessarily reflect those of my employer and number three I do not endorse any specific uh piece of equipment for this video this is just the stuff I have on hand to show you with all of that being said let's jump into it a finger thoracostomy is used to relieve what's known as a tension pneumothorax a tension pneumothorax is when one of your lungs collapses and pressure begins to build in your thoracic cavity this pressure will eventually push over your media dyum collapsing your gra vessels stopping your heart and eventually leading to death this is a state known as obstructive shock so the signs and symptoms of a tension numo thorax are varied and can be very difficult to identify in the field the patient is first going to start complaining of an increased work of breathing if they're conscious if the patient is uh receiving bag valve Mas respirations the person that's bagging them might start having difficulty getting that air in if they're on a ventilator then you're going to see an increase in their Pips their Peak inspiratory pressures now you can also start looking at mechanism if this was chest trauma OB obviously my index for suspicion for attention pneumothorax is going to be much much higher now some other symptoms are going to be very similar to any other shock case you're going to see hypotension and initially you're going to see Tac cardia followed by bra cardia when they start decompensating if you osculate their lungs sometimes you will hear uh diminished lung sounds on one side of the chest now from personal experience when I had a pneumothorax I didn't have much lung Mass on one side of my body and they could still oscal on both sides so you're not always going to hear diminished lung sounds on one side or another and we all know it's going to be very hard to osculate effectively in the back of the ambulance going to a hospital with all of that road noise now one of the very late signs you're going to see is you're going to see that trachea deviating off to the side opposite of the injury so if they have a left side of pneumothorax you're going to see that trachea deviating to the right this is a very late sign and you should have intervened long before it gets to that point just be aware that something you might see so it is worth noting in a traumatic scenario the patient is far more likely experiencing hemorrhagic shock than obstructive shock that's not saying we're not treating a tension in with thorax right away upon identification but we should have it in the back of our mind so now that the background's out of the way let's talk about the procedure itself a finger thoracostomy can be performed very quickly in under 20 seconds when you have enough practice in the procedure for this procedure we only need a couple things first and foremost we need a appropriate PPE that's going to be gloves and preferably some kind of face mask because it is possible for blood to spurt and get us in the face especially if this is a hemo pneumothorax next we're going to need a size 10 scalpel we're going to need a kind of curved Kelly forceps and then we're going to need some kind of occlusive dressing I recommend a chest seal of some kind a vented chest seal is even better now you can get packaged kits that have everything you need this is one such kit um but the these have a lot of stuff in them that you absolutely don't need I don't think this is a necessity when you're performing the procedure so let's talk about the site of this procedure this procedure is going to be performed at the fourth or fifth intercostal space now you can see right here this is exactly where we're supposed to do it so it kind of gives it away on this dummy but as a rule of thumb we don't want to go inferior to the infr mamor fold that's kind of the crease of the breast right here obviously nipple line has been used for many many years but the problem with a nipple line placement is that nipples vary between you know the 80-year-old granny and the 25-year-old bodybuilder it's just not a very um accurate Landmark for you to use so we don't want to go lower than that infr memory fold we also don't want to cut into the pectoralis major muscle as a general rule of thumb we've got the axillary line right here which divides the body in half this way and the anterior axillary line which is right here we want to be somewhere in between those two sites and like I said the fourth or fifth um intercostal space so right here right at that infrom memory fold I'm going to have the fifth intercostal space and then obviously right above that I'm going to have the fourth intercostal space as a general rule it's safer to go a little bit higher because especially in our high BMI patients some of that body mass can actually push their gastric contents up into their chest a little bit higher obviously we do not want to be doing a thoracostomy into the small intestines that's going to be a bad day for everybody involved so a couple different ways to find this site um one of kind of the ditch medicine methods is to take the patient's hand jam it up in their armpit pretty high and then where their pinky Falls is going to be around the fourth intercostal space right here um and you can feel that right here on this dummy so let's go down to the table I'm going to demonstrate this procedure and talk through it as I go and then I'm going to show it again in real time just to kind of drive home the Simplicity of this procedure all right so I have my PPE on obviously I don't have face mask because this is a fake patient and I really hope it's not going to spurt blood at me we have my size 10 scalpel right here my curved Kelly's and then one thing I forgot to mention earlier is uh have some kind of prep pad you know you should really clean this site before you start cutting the reality is in the prehospital environment that uh none of this is a sterile technique there is a drape in this kit um obviously you have the time to drape and make this a sterile technique Do It um but usually in the prehospital environment there's nothing sterile about this we're just going to do our best to be aseptic so when we're starting this procedure first thing we're going to do is identify um the site so right here I can feel um the rib that I want right here now I'm going to go on the uh inferior rib to my sight so right here is the intercostal space Here's the rib under underneath uh each rib you have this neurovascular bundle so you want to be really careful not to cut into that otherwise you're going to have a much worse day than you were having already I'm going to open uh these supplies and get them ready for the procedure itself once again trying to stay at least somewhat um you know aseptic here and then we've got the uh scalpel I have my sight I'm going to wipe that sight down as much as possible and make it uh as pretty as possible I once again I'm going to find the rib I'm cutting on now I'm going to make an incision directly over um that rib I'm going to make this incision probably 3 to 4 cm long um the literature kind of uh changes depending on who you ask but as a general rule of thumb you want to go bigger rather than uh smaller because you need enough room to get your uh finger and your Kelly Clamp CLS into it so now that I have that uh incision created I'm going to take my finger and put it just a little ways up the Kelly clamps this finger is just a safety to make sure I don't insert uh too far now I will warn you this uh mannequin doesn't have a very good plural space so it's a little bit hard um to get in there and actually see the pop but what I'm going to do is I'm going to come in contact with that rib I'm going to slide over it with the clamps and I'm going to pop into that plural space now the next thing I'm going to do is I need to make sure this hole is big enough for my finger is I'm going to start doing a blunt uh dissection so I'm going to take this here and I'm going to open the Kelly clamps and I'm going to start pulling out now different people say different things sometimes they just have you pull out I've seen docs kind of start that there and then they'll twist it and start pulling out you're just making that hole big enough for your finger uh in general now I'm going to take the clamps out I'm going to put my finger in and I'm going to do a sweep around on the inside of the chest and with that I'm trying to remove uh ad eions and I'm also making sure I'm in the right space if that lung is inflating I might feel that lung tissue kind of pushing up against my finger it's um very spongy and obviously that's something we want to feel now once this is relieved we've hopefully heard that whoosh or the patient's hemodynamics have started to improve then I'm going to take my finger out and I'm going to apply some kind of eclusive dressing right here it's a hyphen chest seal if the patient experiences uh this pneumothorax again all I have to do is peel back that sight get my finger and then reopen the finger thoracostomy I don't necessarily have to cut again it is once again really important that we're cutting on the lower rib and then moving up over that to so we're avoiding that neurovascular bundle [Music] so one potential risk with this procedure not necessarily to the patient but to you if they have a tension pneumothorax chances are they also have rib fractures to go along with it I've never heard of somebody doing this but hypothetically there's a risk of you inserting your finger into their chest and as you're doing your sweep or puncturing down you could cut your finger on a sharp jagged edge of a bone and then of course um you're in a very bloody environment so that's going to be a very bad exposure for the provider uh and potentially for the patient so just be aware of that that and be cautious so that's all I have for this video guys I hope you found it useful if you have any comments questions snide remarks leave them in the comments down below and I will see you next week [Music]