I know I am “stirring the pot” among a respectable number of EMS providers, but, I think that some of the most important goals when we practice any type of healthcare-related-activities, is to keep increasing your knowledge, assume nothing, investigate, and find new ways to improve patient care.
There is some terminology that has been used lightly -in my humble opinion- in several written publications as well as medical podcasts related to Tension Pneumothorax (TPT)1,2,3,4 and the way it is and should be treated by EMS providers -specifically Paramedics, Critical Care Paramedics or HEMS crews- which, I’m convinced, create more confusion, increase the on-scene time, are potentially harmful, inaccurate, and sometimes mislead to a successful outcome, especially in novice providers.
New terminology, and in some cases, variations of existing approaches, is not always needed to explain medicine, physiology or pathophysiology. What we need is to adhere to the facts, apply our knowledge and skills and therefore act consequentially.
I intend to defend my arguments with facts and prove, that we don’t need new terms to explain medicine, physiology or pathophysiology when we are referring to TPT.The “current" state of the art. In several scientific papers, medical reports, case reviews, podcasts and blogs, we are seeing a lot about this procedure called... “Finger Thoracostomy” (FT)1,2,3,4. Call it a “Trend” Well, let’s have a talk, Shall we?
Finger Thoracostomy is a made-up term... That’s it... I said it! Wow! It is liberating!!!
At this point, dear reader, you must be shaking your head and saying: What is this guy talking about? Let me explain myself.
The term Finger Thoracostomy” (FT), started to be seen in the literature around 1995. It was first used as a synonym for a procedure described as “Simple Thoracostomy” (ST) published by a HEMS Crew in London5. After that publication, some authors started to refer to ST, a.k.a. “Finger Thoracostomy”.
Let’s go back to basics: Thoracostomy is a surgical procedure where following a clean and precise surgical technique, a man-made communication is created between the thoracic cavity and the exterior. The oldest reference to a thoracic drainage, dates from the Hippocrates era -Fifth Century, 460-370 B.C-6, Etymologically, it derivates from two Greek roots: thoraco=chest, and ostomy derivates from the word stoma=mouth. Hence, it means: “the surgical formation of an opening into the chest cavity, as for drainage”.
If you have ever performed a Thoracostomy (either pre-hospital or in the ER), You better have Jackie Chan’s “Ten fingers of death” or have someone like him to pry a parietal pleura open with your bare fingers! So, FT is a made-up term. Sorry, but in the medical field, we need to not only know the substance, but follow the form. You don’t need to call things something different just to prove a point. The medical terminology is beautiful the way it is, and changing words doesn’t make it better. In my mind, when you say FT it means that you are performing that procedure with your finger, and that’s just not true!
ST is a surgical procedure that requires constant and frequent surgical training to speed up your learning curve, being not short of complications, and, if not performed correctly will threaten the patient’s condition. The justification for FT is that in a Tension Pneumothorax situation, a swift and effective way to correct the hemodynamic compromise caused due to the shift of the major vessels by the acute air entrapment is needed. Granted, the bigger the hole, the faster the drainage; but, Isn’t that the reason for the chest tube insertion? How much longer will it take for a provider to insert a chest tube once the pleural cavity is open and the pressure is relieved?
I know it is not a lot! So, instead of performing an incomplete surgical procedure, if the immediate life-threat is resolved, then, take a deep breath, chill out, and insert the tube! The patient will appreciate it! -and as a plus-, you will have fewer things to care about, such as trying to keep that darn hole open!
I also have heard and read (from very respectable sources)3,4,5 that when you perform a FT for a TPT, you introduce your finger inside the pleural cavity and swipe in a circumferential pattern to remove adherences, and even state that they are able to touch the lungs!
About that, if you are performing a ST for a real TPT, chances are the lungs will be pushed away to the opposite side (Fig 1) in a way that, unless you have Alien-like long fingers, you won’t be able to reach for it. I’d point out that this statement has been made by providers who claim that they are treating a TPT!3,4,5 Also, regarding the adherences, it is very unlikely that a complete lung collapse and a shift of the major vessels can be present. Every inflammatory condition related to the pleura, (Pneumonia,Empyema, some types of Cancer, Emphysema) can, and in some cases will lead to formation of firm adhesions between the two pleural layers (parietal and visceral) also, surgical procedures such as Pleurodesis, will fuse these two structures, making almost impossible to observe a TPT, unless a severe damage to the pulmonary parenchyma is present.
Where am I going with this? What I am trying to point out is that we need to increase our level of awareness related to the fact that we are not diagnosing properly TPT and we are overdoing things. Unfortunately, there isn’t enough available data from the field that we can use to support the decision to perform a procedure. I have spent a lot of time reading different reviews and all of them have the same outcome: More information is needed.
The fact that we are still not able to measure the prevalence of TPT in the pre-hospital settings, like Mistry found TPT in traumatic arrest in 5.7%7, while Leech called it for 0.4% in major trauma patients8. On the other hand, more than 64% of the TPT is observed in mechanical ventilated patients9, and most of the data is retrospective, leading me to question the way we are handling those patients after intubation. Even though, the data is old, you see no changes among the prevalence in more recent series.
Plus, we need to acknowledge that TPT is a very difficult entity to diagnose with unspecific symptoms and findings that can mimic other acute conditions and lead to mistakes by providers. There is a very interesting review from 2005 that compares the findings in awake vs. ventilated patients11, and gives a list of common, reliable and unreliable signs of TPT. I highly recommend this lecture for all providers.
This is a compilation of classical signs and symptoms of TPT according to different reference books and systematic reviews of literature12: Hypotension; Hypoxia; Absent breath sounds; Tachycardia; Chest Pain; Shortness of breath; Tachypnea; Cough; Fatigue; Cyanosis; Deviated Trachea; Hyper-resonance; Jugular Vein distention. I dare you, my dear reader, let’s try to cite at least 4 clinical entities where you can observe the same “Classic Manifestations “of a TPT. One of the first that comes to my mind is a Pulmonary Embolism (PE). Would you either Needle Chest Decompress (NCD) or ST a patient that falls into this category?
Scary, I know. Specially if you are out in the field with no resources.
It is worrying, because the traditional signs and symptoms that we are encouraged to learn are unreliable and can only appear in late stages of the TPT10.
The “Tension Physiology” issue. Sorry, there is nothing “physiological” in hemodynamic changes observed after a TPT. Fig.1 Typical displacement of the great vessels and trachea in a true TPT.
In Greek, means “Natural Philosophy” and In Latin, the root Physio, means physical and logos=logy means science. In the 17th century, the merge of these two roots created the discipline physiology that deals with just about everything that keeps us alive and working. -In normal conditions- So, as previously stated, there is nothing physiologic in that terminology. So, please refrain from using it.
Probably, some providers would reply saying that this is irrelevant, and it is just another word. I respectfully disagree. What makes us, healthcare providers different from the rest of the people, is that in this field, we must learn how to express ourselves in a precise and professional manner. As one of my professors used to say: “You are clinicians now”. We are, day-to-day, influencing new generations of providers and public in general, not only with our actions, but the way we communicate effectively and clearly.
The Facts and Myths in TPT (or the good, the bad and the ugly if you will)
Fact: Finger Thoracostomy is not a thing. We need to start using the terminology properly. Simple thoracostomy or Thoracostomy.
Fact:Tension Physiology doesn’t exist. There is nothing physiological on that terminology. Just describe the events or refer as consequences of an untreated TPT.
Myth:Every Pneumothorax will become TPT if not treated accordingly13. Not necessarily, a marginal pneumothorax can be treated conservatively and has the potential to resolve spontaneously. Also, a simple pneumothorax can and will create a collapsed lung, but not necessarily the hemodynamic complications observed in a TPT will develop. (Figs. 2 and 3) We cannot be absolute in Medicine. There is an adage among Hispanic doctors that translates: “In medicine, 2+2 it never equals 4”. And that’s true!
Myth:The association of Hypoxemia, Hypotension, Decreased level of consciousness and chest pain with Hyper-resonance are sound evidence of a TPT. These signs are rarely observed together -specially in awake patients- and are case-by-case dependent11.I want to make an observation at this point: some very respectable providers will argue that we don’t have X-Rays in the field, and this is true, but, what is also true is, as professionals, we are compelled to be curious, run the extra mile if you will, and make an extra effort to try to understand the complexities of the entities that we deal in a day-to-day basis, and every inch of knowledge that can help us to understand what can be wrong with a patient, and how to help in an emergency will make us better professionals.
TPT is a very complicated and life-threating condition that needs to be carefully taken into consideration in the management of a chest trauma patient11,12, with a low prevalence and a high-risk of misdiagnosis, a more expectant approach until a firm diagnosis is made, it will lead to a lower rate of complications. A definitive shift in the major vessels axis that is traduced in a hypotensive status in absence of massive bleeding, a tracheal deviation and chest hyper-resonance with percussion of the chest in absence of lung sounds might become good probable signs of a TPT, sadly, not every patient will exhibit these signs from the start.
A continuous monitoring of the patient upon arrival on scene, during loading and transport, keeping a high index of suspicion, combined with strong anatomical and pathophysiologic basic knowledge, and sharp surgical skills is of paramount value when this condition is observed.
More research in the field is needed. The continuous gathering of data that can measure the real prevalence of the phenomenon, and the reporting of success-fail ratios is what definitively will allow us to improve our diagnosis and management at the prehospital level. The continued training and the adherence to pre-defined surgical techniques, the proper use of instruments, and I can’t stress enough the “When-not-to” philosophy, is what ultimately will allow us to become greater clinicians and better providers.
More realistic simulation tools and scenarios, as well as an out-of-the-box critical thinking, paired with implementation of non-invasive, advanced tools; i.e. Point of Care Ultrasound (P.O.C.U.S) -but at the same time, understanding that these are just additional diagnostic tools- will change the outcome of patients in the upcoming years.
Be active, be proficient, keep researching new ways and improving your knowledge, but above all... Be safe out there!
Quoting the words of Dr Theodor Kocher (1841-1917):
...” A good surgeon is a doctor who can operate and knows when not to operate” ... ...Or any provider, for that matter....(Me, 2018).
Herfrank J Loyo NR-P Paramedic at Lifestar Emergency Services. Waupun, WI Paramedic at Divine Savior EMS. Portage, WI Firefighter/AEMT Marshall Fire Department and EMS. Marshall, WI MD. Trauma/General/Laparoscopic Surgeon in Venezuela.
Bibliography
1,2 Jodie. P, Kerstin. H. BET 1: Pre-hospital finger thoracostomy in patients with traumatic cardiac arrest. Emerg Med J. 2017;34(6):417-418
3 Scott Weingart. EMCrit Podcast 16 – Coding Asthmatic, DOPES and Finger Thoracostomy. EMCrit Blog. Published on December 23, 2009. (Accessed on August 15th, 2018). Available at [https://emcrit.org/emcrit/finger-thoracostomy/ ].
4 Cynthia Griffin. FOAMfrat Podcast 51 - Finger Thoracostomy Part 3 FOAMfrat Blog. Published in July 8th, 2018. (Accessed on July 10th, 2018). Available at [https://www.foamfrat.com/single-post/2018/07/08/Podcast-51---Finger-Thoracostomy-Part-3].
5 Deakin, C. Simple Thoracostomy Avoids Chest Drain Insertion in. The Journal of Trauma: Injury, Infection, and Critical Care, 39(2):373-374.
6 Walcott-Saap. S, Sukumar. S. A History of Thoracic Drainage: From Ancient Greeks to Wound Sucking Drummers to Digital Monitoring. Web Article. CTSNet.org. Available at
[https://www.ctsnet.org/article/history-thoracic-drainage-ancient-greeks-wound-sucking-drummers-digital-monitoring]. (Accessed on Aug 04, 2018)
7 Mistry N, Bleetman. A, Roberts. KJ. Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest. Emerg. Med J., 26(10):738-740.
8 Leech. C, Porter. K, Stein. R, et al. The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh. Trauma, 19;(1).
9 Coats. T, Wilson. A. Xeropotamous. N. Pre-hospital management of patients with severe thoracic injury. Injury, 2: 581-585.
10 MacDuff A, Arnold. A, Harvey. J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guidelines 2010. Thorax; 65(Sup II).
11 Leigh-Smith, S. Tension pneumothorax—time for a re-think? Emerg. Med J;22: 8-16.
12 Roberts.D, Leigh-Smith. S, Faris. P, et al. Clinical presentation of patients with tension pneumothorax: A systematic review. Annals of Surgery. 261(6): 1068-107813 Ruiz. C. Thwarting the pneumothorax. American Nurses Association Journal. 2011 6 (5) N/A Jodie. P, Kerstin. H.
BET 2: Pre-hospital finger thoracostomy in patients with chest trauma. Emerg Med J. 2017;34(6):419