Category Archives: Thorax

Technique, Thorax

The “Backward Finochietto” Problem

Resuscitative thoracotomy is a (sometimes) life-saving procedure reserved for trauma patients in extremis. Thankfully, most trauma centers do very few of these a year. However, that makes it one of those “high severity – low frequency” procedures that generate many, many quality improvement problems. Many of these issues are due to operator unfamiliarity or equipment availability.

Today, I’ll highlight a problem that occasionally crops up at trauma centers across the US: the “backward Finochietto.” One of the most essential components of the resuscitative thoracotomy is rapid access to the chest. A large skin incision is typically made, the thoracic wall and intercostal musculature are divided, and the pleural space is entered.

It’s not easy to insinuate your arm between the ribs in an average person. But, of course, there’s a retractor for that! Von Mikulicz presented the first rib spreader at a German surgical society meeting in 1904.  Various versions of this instrument were devised over the next three decades to make it easier and faster to use.

The Finochietto retractor was introduced in 1936 and boasted several enhancements. It used a rack-and-pinion system to make it easier for the surgeon to spread the chest wall and to make it unlikely to close on its own. The turning lever was hinged so it could be flattened and placed out of the surgical field. The blades had fenestrations so that chest wall tissue could protrude into them, preventing it from slipping when opened. It remains a workhorse instrument for us today and is found in most instrument packs for resuscitative thoracotomy.

But there is a potential problem. Some Finochietto retractors consist of only two pieces: a blade with the linear gear teeth (the rack) and another blade that fits onto it with the turning handle (the pinion). See the image below:

Looks great, right? However, there is one downside. The retractor parts that hook into the soft tissue are of a fixed depth. What if your patient has a more generous body habitus? Placing multiple sets of this retractor in the thoracotomy pack is impractical.

The solution is to allow detachable blades of various sizes. Here’s a modern-day example:

The good news is that the retractor tips are interchangeable. The bad news is that they are sometimes interchangeable with the wrong arm of the retractor! Hence the “backward Finochietto” problem. It’s impossible to use the retractors with the blades on the wrong side, and it takes time the trauma professional does not have to figure out how to snap them off and switch them around.

So what’s the solution? This is clearly an instrument reprocessing quality issue. These instruments are expensive, so your hospital may not be eager to purchase new ones specifically for the trauma bay. It all boils down to foolproofing it in as many ways as possible.  Here are some tips:

  • Provide an educational session for all of the reprocessing techs. Unfortunately, this effect will wear off as staff turnover occurs.
  • Post a photograph of a properly assembled retractor for the techs to use when processing the tray.
  • Use colored instrument marking tape on each piece of the instrument. For example, a green tape strip should be placed on both the retractor’s rack arm and the left blade. Use red tape for the pinion arm and the right blade. All the tech needs to do now is match the colors while assembling the retractor.

Bottom line: This problem is more common than you may think. Ask one of your old-timer trauma surgeons, and I’ll bet they can tell you some stories. But it is easily avoided with a little creativity and some tape! Be sure to do it now so it doesn’t pop up in the heat of a resuscitative thoracotomy.

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Thorax

Survival After Penetrating Injury To The Heart

Penetrating injury to the chest, and especially the heart, has a high mortality rate. The best way to reduce mortality is rapid pre-hospital transport to a trauma center where life-saving measures can be carried out immediately. Frequently, these measures include resuscitative thoracotomy. The Western Trauma Society has a well-known guideline to help with decision-making in performing this procedure.

The trauma group at Sinai Chicago recently published a paper slicing and dicing the possible predictors of survival after cardiac injury. As I read this paper, I was curious about how this information would change our practice, especially with the decision to open the chest.

The authors performed a retrospective cohort study of patients who had suffered penetrating cardiac trauma over nine years. Here are the factoids:

  • Over 18,000 patient encounters were analyzed (average 2,000 per year), and only 57 penetrating cardiac injuries were identified (3%)
  • Overall survival was 25% (!)
  • Gunshot victims were 3.7x more likely to die
  • Mortality odds ratios for specific injury patterns were as follows:
    • Multiple cardiac chambers injured 11x
    • Thoracic vascular injury 12x
    • Concurrent abdominal injury 4.4x
  • These findings were noted to decrease the likelihood (odds ratio) of death:
    • Isolated cardiac injury 0.2x
    • Spontaneous respirations 0.06x
    • Signs of life on arrival 0.01x
  • Every patient (35) who underwent resuscitative thoracotomy died

The authors suggested that recognizing these factors could help clinicians in decision-making processes during early triage and resuscitation.

Bottom line: When I first read the paper, it seemed that this was all common-sense information and didn’t add much to our body of knowledge. However, upon closer reading, there are some good tidbits here. The work here helps identify which patients are most likely to benefit from opening the chest. It assigns probabilities to anatomic and physiologic criteria, some of which are apparent at the time of patient arrival and are available for decision making. The fact that every patient who underwent resuscitative thoracotomy died is not alarming; it merely reflects the fact that these are patients who are the sickest of the sick. 

So how do we put the information in this paper to use? The resuscitative thoracotomy algorithm from the Western Trauma Association should be utilized first. When the patient is on the cusp of the 15-minute CPR decision point, the odds ratios in this paper might be used to tilt the scales one way or the other. Does the patient also have abdominal injuries? Are there no signs of life? Then perhaps clinician judgment may dictate that the procedure not be performed. Alternatively, if the thoracotomy is carried out in patients and any of the three high-risk anatomic indicators for death are present, they might then choose to terminate the procedure to conserve resources. 

Overall, this paper does not force any major changes in care. It informs the trauma professional and allows them to couple that information with existing algorithms and care processes, so they might either further improve the patient’s probability of survival or conserve scarce resources if survival is unlikely. 

References: 

  1. Predictors of survival after penetrating cardiac trauma: injury patterns and presentation factors. Trauma Surg Acute Care
    Open 2026;11:e002237.
  2. Western Trauma Association Resuscitative Thoracotomy Practice Guideline
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Technique, Thorax

How Good Is The Erector Spinae Plane Block?

In my last post, I shared a video outlining the technique for providing an erector spinae plane block (ESPB). Today, I’ll review the most recent analysis of this procedure’s efficacy and safety.

As outlined previously, the ESPB targets the plane between the fascial layers of the thorax, providing analgesia in patients with rib fractures. The technique for use in trauma is relatively new, was first described in 2016, and studies on its effectiveness are finally beginning to accumulate. The most recent and comprehensive was recently published in the Clinical Journal of Pain by a group from Taiwan.

The authors performed a comprehensive search of papers published through 2025. They included only prospective studies comparing pain relief from fascial plane blocks (both ESPB and serratus anterior plane block (SAPB))  with epidural analgesia or no block. They identified only nine papers that included 600 patients, but only 5 used ESPB.

Here are the factoids:

  • Overall, fascial plane blocks in general (both SAPB and ESPB) significantly improved subjective pain scores during the first six hours, but were not after that for patients not receiving an epidural
  • When looking at SAPB alone, pain scores were improved during the first 24 hours; with ESPB alone, they were only improved during the first 6 hours.
  • Both types of plane blocks achieved pain scores similar to epidural analgesia
  • Both blocks decreased in-hospital opioid use, but this was not statistically significant
  • Hypotension occurred significantly less with fascial plane blocks compared to epidural analgesia
  • There was no difference in hospital length of stay with plane blocks compared to standard treatment

Bottom line: What does it all mean? First, there is still too little data to distinguish nuances in outcomes when comparing ESPBs and SAPBs. However, it appears that plane blocks result in less hypotension and so are a bit safer. However, subjective pain scores are only improved during the first 6 hours with ESPB. This suggests that there may be a significant placebo effect for this invasive procedure. Opioid use is the same.

With the exception of the first six hours, ESPB doesn’t look that exciting. It requires special equipment (ultrasound) and a trained provider to perform. It works as well as an epidural, which makes it more useful in patients with contraindications to this modality.

My take is that this may be a promising technique, but it’s still a bit too early to tell. This “large” series included only 600 patients, and fewer than half had the ESPB. So keep studying this procedure to see if it makes sense in the future.

Reference:  Efficacy and Safety of Serratus Anterior Plane Block and Erector Spinae Plane Block for Rib Fracture Pain: A Systematic Review and Meta-analysis. The Clinical Journal of Pain 42(2):e1334, February 2026. | DOI: 10.1097/AJP.0000000000001334

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Technique, Thorax

What Is It: The Erector Spinae Plane Block

Chest trauma is extremely common, and the incidence is rapidly increasing in the elderly population, with the rapid increase in falls. Rib fractures are always a concern, and the most important factor in their management is pain control.

Over the years, numerous modalities have been described, including:

  • Decreasing rib motion using taping or rib belts (highly discouraged due to the incidence of complications)
  • Systemic pain medication (may cause respiratory depression)
  • Epidural analgesia (contraindicated in patients on anticoagulants)
  • Intercostal nerve (rib) blocks (not all ribs accessible)
  • Intrapleural analgesia (not very effective, with unpredictable absorption and spread)
  • Rib fixation procedures
  • Erector spinae plane blocks

In general, we have been moving from more general to very focused pain control. Analgesic usage has predominated, with operative procedures recently becoming more common for select patients.

The new kid on the block now is the erector spinae plane block (ESPB).  It is technically easier to provide relief for rib fractures at most levels. It involves small injections and is relatively simple to perform under ultrasound guidance after proper training.

This video is a good introduction to the general concepts and techniques for the ESPB. Obviously, watching a video will not give you the skills to do this yourself. Work with a trained professional to gain experience with this technique.

YouTube player

In my next post, I’ll review the data on the efficacy and value of this block.

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Thorax

Can I Keep Patients With More Than Three Rib Fractures At My Level IV Trauma Center?

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Rib fractures are one of the most common thoracic injuries presenting to trauma centers. Traditionally, many state designation standards set limits on the number of rib fractures in patients to be admitted to Level IV trauma centers. The assumption was that these centers had limited surgical capabilities and might not have the expertise to manage them to achieve optimal patient outcomes. They were then forced to transfer these patients upstream to a higher-level trauma center.

And then, unfortunately, COVID came along, and things changed. Mainly for the worse. Due to reduced professional staffing throughout the entire continuum of health care, the upstream centers are saturated and have limited availability to absorb patients who don’t take advantage of their increased resources.

Both staffing and reimbursement issues strain rural EMS agencies. It is difficult to justify transferring a patient to a center that takes the only ambulance in the community out of service for a good portion of the day. Also, most current state trauma system standards do not fully appreciate non-surgeon clinicians’ interest and skill levels at those Level IV centers.

The Pennsylvania Trauma Systems Foundation recognized these issues at the centers in its state. In 2020, it opted to liberalize the number of rib fractures that could be treated at Level IV centers. It required hospitalists to be current in ATLS in order to admit these patients. The centers were also required to adhere to a chest injury guideline created for them.

To gauge the safety and effectiveness of this change, a retrospective state registry study was performed comparing patients admitted during the 2.5 years before the standards change to the 2.5 years after. Demographics, injury characteristics, length of stay, and mortality were compared between the groups. Patients were excluded if they had significant injuries in other body regions, were age < 18 years of age, or had complicated fractures (requiring supplemental oxygen on admission, concomitant pneumothorax or hemothorax, pulmonary contusion or laceration, or who did not require admission

Here are the factoids:

  • Over 4,000 patients were recorded in the registry during the 5 years, but 3350 were excluded due to the definition of complex rib fractures
  • A final total of 1,070 patients were included, with 710 admitted to Level III centers and 360 to Level IV centers
  • This left 132 Level III patients and 228 Level IV patients in the pre- and post-standard groups, respectively
  • The number of transfers out of the Level IV centers dropped significantly, from 56% to 21%
  • Patients with <3 rib fractures had the same length of stay as those with more than three (3 vs 2, respectively)
  • Mortality was extremely low and not significantly different based on the number of rib fractures

Bottom line: This study showed that the change in admission standards for rib fractures in Pennsylvania did not impact outcomes and resulted in significantly fewer transfers.

The key to a successful change like this involves education and protocols. The requirement that hospitalists be current in ATLS is beneficial because it gives them a better understanding of the physiologic effects and priorities in managing trauma patients. A well-designed practice guideline is critical so that all clinicians apply best practices in caring for these patients. 

This is an important paper, and should be considered in any state where local resources are being challenged, and hospital reimbursements are declining. This type of standards change may breathe new life into many of our Level IV centers.

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