# Field Tx of Pneumothorax



## HoosierAnnie (Nov 1, 2008)

Calling all you 18D's 

I've got a scene where the 18D is careing for two wounded guys post helo crash.  One has an obvious pneumo.  I know about care once you guys get them to me in the hosp, but I need field care.  Esp in a combat situation awaiting evac into what is, at the moment a hot LZ. 

Is there something like a flutter valve to place?  An occlusive/sealant dressing around it? Would you use morph for pain control even with its know resp depressive function?  With the crash I'm thinking rib fx's is the causative agent rather than open wound.  Injured guy is a fellow SF, high ranking NCO (think CSM-type)

Thanks Guys (damn I'm racking up one helluva bar tab)


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## Ajax (Nov 1, 2008)

Treatment:  four-sided occlusive dressing over entrance and exit (Ascherman chest seal if you want to do product placement), with needle thoracentesis using 12 or 14 gauge over intersection of 2nd intercostal space and the midclavicular line (about half way between the nipple and the collar bone.  Also called a needle drill, this treatment would only be given if the pt displayed symptoms of respiratory distress (decreased rise and fall of affected side of chest, decreased breath sounds, labored breathing, JVD, hyporesonance with percussion (tapping on a rib and feeling like your hitting a solid peace of wood as compared to a drum like the healthy side), decreased 02 saturation, tracheal deviation, etc).  Chest compromise in itself is not an indication for decompression.

This treatment is different than civilian protocols and some military protocols in that it uses a four sided occlusive dressing rather than a three sided.  Until TCCC was introduced, most line units were not authorized or trained to decompress a tension pneumothorax.  The three-sided dressing allowed air to escape on expiration, but generally sealed the wound on inspiration.  A four-sided just seals the wound, leaving it up to the operator to decompress as needed.  It is fairly obvious when this needs to happen. 

A commercial chest seal, regardless of what brand, is self burping with a flutter valve and is occlusive on all sides.  Rick Ascherman, the inventor of the ACS, was a Force Recon Corpsman and an 18D instructor.  The competitor that I know of is North American Rescue Products, which was founded by a PJ and has a pretty strong R&D department.

NOTE:  A "stop gap" of anything plastic is often used as a hasty treatment during an intial survey or if there is still a chance of lead poisoning.  This can be held in place by equipment (IBA, etc) or the patient.

On Morphine:  yeah, I'd still use MS on him if he was a barrel chested freedom fighter, but sparingly.  2-4mg.  Again, that is way different than street medicine.  2-4mg for trauma management pain management is a piss in the bucket when you're dealing with guys that are used to "walking it off", especially bigger guys.  I would also hang it in a bag so I can titrate to effect.  If he starts to shit the bed, I can turn it off, and vice versa.  And, this may sound stupid, but Ranger Candy (800mg Motrin), still works in trauma.

I haven't been out to Bragg in a while.  

Cric, what's the current war wound therapy?


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## HoosierAnnie (Nov 1, 2008)

Is gonna owe Ajax a whole lot o beers.  TY.


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## Ajax (Nov 1, 2008)

bored out of my skull.  Wish I wasn't  geographically challenged in order to collect.


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## PunchDrunkCasper (Nov 1, 2008)

Ty, nifty piece of info, especially because I've had a pneumo in the past.


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## Muppet (Nov 2, 2008)

Ajax, is this worth any C.M.E.'s? I have to re-cert my ITLS instructor cert.

F.M.


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## surgicalcric (Nov 2, 2008)

Ajax said:


> Treatment:  four-sided occlusive dressing over entrance and exit (Ascherman chest seal if you want to do product placement), with needle thoracentesis using 12 or 14 gauge over intersection of 2nd intercostal space and the midclavicular line (about half way between the nipple and the collar bone.  Also called a needle drill, this treatment would only be given if the pt displayed symptoms of respiratory distress (decreased rise and fall of affected side of chest, decreased breath sounds, labored breathing, JVD, hyporesonance with percussion (tapping on a rib and feeling like your hitting a solid peace of wood as compared to a drum like the healthy side), decreased 02 saturation, tracheal deviation, etc).  Chest compromise in itself is not an indication for decompression.
> 
> This treatment is different than civilian protocols and some military protocols in that it uses a four sided occlusive dressing rather than a three sided.  Until TCCC was introduced, most line units were not authorized or trained to decompress a tension pneumothorax.  The three-sided dressing allowed air to escape on expiration, but generally sealed the wound on inspiration.  A four-sided just seals the wound, leaving it up to the operator to decompress as needed.  It is fairly obvious when this needs to happen.



Steel on target Brother...

In addition to the commercially available ACS's there are Bolin Chest Seals (BCS is similar to the ACS but it has 3 valves instead of the single 1-way as well as the adhesive is a lil better) and Hyfin Chest Seal which is a 4-sided occlusive dressing which will stick to anything (they remind me of the older defib pads.)  

The needle drill is but a stop gap measure to buy the medic and the patient time until a tube thoracostomy (chest tube) can be performed.  The chest tube is the definitive treatment for a tension pneumo/hemothorax.  In the interest of the scenario provided, the chest tube should be placed while awaiting the EVAC platform (hopefully MEDEVAC) with a pleura-vac on board.

The amount of time I am have the patient will determine further treatment(s): ie: IV fluid choices, pain management (as talked about earlier by Ajax), war wound therapy (if conscious the patient is getting Gatafloxacin 400mg, or if unable to protect his own airway 1gm Ertapenim IM), etc...

HTH,

Crip


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## HoosierAnnie (Nov 2, 2008)

Adding Crip to the beer list. Thanks from both me and my fictious 18D SFC Wilson


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## Ajax (Nov 2, 2008)

Firemedic said:


> Ajax, is this worth any C.M.E.'s? I have to re-cert my ITLS instructor cert.
> 
> F.M.



Don't know brother.  Let me ask my med director.  He's humping around the Kush right now, so it won't be a quick answer.

Cric, thanks.  Forgot all about those other seals.

Hoosier, if you really want him to get crazy, he can thow an 8.0 ET tube into his chest if he doesn't have a chest tube on his person.  (They're bulky, depends on what kit he has with him.  It was a  hide site, right?)


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## HoosierAnnie (Nov 2, 2008)

Yeah a hidey hole just waiting for things to get dark again so they can complete the assigned mission. The reader will be experiencing this scene from the point of view of the guy with the pneumo, so yeah making things a lil tenser would be good. Wincing in sympathy, damn son, an 8.0 ET, OUCH.


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## Ajax (Nov 2, 2008)

don't forget to inflate the cuff


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## Rabid Badger (Nov 2, 2008)

Wow!!.....I'm living vicariously through you guys!!!! ;);)

Many many beers later.......;)


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## HoosierAnnie (Nov 2, 2008)

Ajax said:


> don't forget to inflate the cuff



DUH  yes Obi Wan


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## surgicalcric (Nov 2, 2008)

Ajax said:


> ...Hoosier, if you really want him to get crazy, he can thow an 8.0 ET tube into his chest if he doesn't have a chest tube on his person.  (They're bulky, depends on what kit he has with him.  It was a  hide site, right?)



Infact, I carry extra 8.0's for that purpose...

Multi-use items in the aidbag is the name of the game.

Crip


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## CAL (Nov 2, 2008)

I can't wait for the next chapter!


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## kaja (Nov 3, 2008)

Just some illustration :)
chest injuries treatment

Petrolatum gauze chest injury treatment


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## Muppet (Nov 4, 2008)

I learned all before but I enjoy listening the the 18-D's convey their knowledge. I had a brigade surgeon who was an 18-D back @ Bragg prior to going to med. school and he taught us about the ETT's as chest tubes. He was trully my mentor. He gave me his flash from his beret from the 3rd. group when I graduated Paramedic school while I was in.

F.M.


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## Muppet (Nov 4, 2008)

Correction, that was Batt. surgeon, not Bde. surgeon. My mistake and I will do push-ups. P.M. me when you want me to recover.

F.M.


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## surgicalcric (Nov 4, 2008)

No.  Recover when you think you have done enough...


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## Muppet (Nov 4, 2008)

I had 3 back to back jobs so I had to recover soon after I wrote this. I am @ work until 07:00 and off to teach.


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## DoctorDoom (Feb 21, 2009)

Data out of LAC showed up to 40% of field placed needles didn't penetrate the chest wall.  Make sure the needle gets in, especially on these barrel chested freedom fighter types! :)


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## TLDR20 (Feb 21, 2009)

DoctorDoom said:


> Data out of LAC showed up to 40% of field placed needles didn't penetrate the chest wall.  Make sure the needle gets in, especially on these barrel chested freedom fighter types! :)



Listen for the woosh is what I was  taught. If you get that you should definently be in the chest cavity


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## surgicalcric (Feb 22, 2009)

cback0220 said:


> Listen for the woosh is what I was  taught...



Using the appropriate length catheter (3.25") and proper placement 2nd ICS MCL or 5th ICS MAL is the key here.   

Good luck hearing that "whooosh" if you are working anywhere other than a controlled setting...  ;)   

Crip


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## Muppet (Feb 22, 2009)

surgicalcric said:


> Using the appropriate length catheter (3.25") and proper placement 2nd ICS MCL or 5th ICS MAL is the key here.
> 
> Good luck hearing that "whooosh" if you are working anywhere other than a controlled setting...  ;)
> 
> Crip



Second on that Crip. I did one a few months back and I heard no woosh. Pt. was still in the wrecked car. I did get better pulses and color back with a slight inprovement in mentation though. Looking for signs of improving v/s. are better that wishing for the woosh. I was able to convince the supply guru @ the squad to buy longer needles for that purpose. People think I am a crazy military medic until the rescearch comes out. Go figure. Civilians.

F.M.


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## JOgershok (Mar 11, 2011)

Are there any studies on these occlusive dressings.  Civilian EMS protocols for PA EMT-B is tape three sides and get ALS intercept.  TCCC is four sides (or other occlusive) and needle decompression.  18-D do have the option of a chest tube in austure conditions.  Is it just limits on scope of practice?


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## TLDR20 (Mar 11, 2011)

I am currently carrying HALO chest seals and I think they are the bees knees, link is here: http://www.itstactical.com/medcom/medical/halo-chest-seal/

I think it is the best thing currently out there, it is sticky as shit, which comes in handy when dudes are sweaty/bloody. Then of course the proper utilization of a needle D, and you are gravy


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## txpj007 (Mar 11, 2011)

cback0220 said:


> I am currently carrying HALO chest seals and I think they are the bees knees, link is here: http://www.itstactical.com/medcom/medical/halo-chest-seal/
> 
> I think it is the best thing currently out there, it is sticky as shit, which comes in handy when dudes are sweaty/bloody. Then of course the proper utilization of a needle D, and you are gravy



Have to concur with the HALO they do stick to anything and do work well.  The ACS where a great idea but ive never been able to get them to stick or stay in place with blood and sweat...ever. One more tip so i can feel like im smart.  A quick way to find your landmark for a needle D is to put your hand  in the pt's armpit (the same way you did when you were a kid making fart noises in school with your hand...lol...thats the best way i can describe it without a picture) and your thumb should line up pretty damn close to mid clavicular 2IC.  Works well with big chested guys when its hard to palpate.


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## Muppet (Mar 11, 2011)

txpj007 said:


> Have to concur with the HALO they do stick to anything and do work well. The ACS where a great idea but ive never been able to get them to stick or stay in place with blood and sweat...ever. One more tip so i can feel like im smart. A quick way to find your landmark for a needle D is to put your hand in the pt's armpit (the same way you did when you were a kid making fart noises in school with your hand...lol...thats the best way i can describe it without a picture) and your thumb should line up pretty damn close to mid clavicular 2IC. Works well with big chested guys when its hard to palpate.



Holy mackrel! Thats great. I teach P.H.T.L.S. / I.T.L.S. and am going to use this Where did you learn that from?

F.M.


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## txpj007 (Mar 11, 2011)

Firemedic said:


> Holy mackrel! Thats great. I teach P.H.T.L.S. / I.T.L.S. and am going to use this Where did you learn that from?
> 
> F.M.



At a TAC/MED refresher a few years back I believe...passed down from an older PJ.


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## Muppet (Mar 11, 2011)

Kewl. Thanks bro. Gotta love them P.J.'s

F.M.


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## Mac_NZ (Mar 11, 2011)

Third on props for the HALOs, we tested them after a 2km BCD on the sweatiest hairiest guy known to man and it stuck like shit to a blanket.  He was not impressed when we took it off though.  Before that we used to carry duct tape to use on the perimeter of the ACS.

I was taught to put a syringe on the end of the catheter (3 1/4") and to watch it rise when you hit the right spot then remove it as we wouldn't hear the air escape.  Anyone else doing that or am I being taught dodgy shit?


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## amlove21 (Mar 11, 2011)

Im gonna co-sign on some stuff here- if you dont have any experience with the HALO, you are using an inferior product. No kidding, that is the best chest seal on the market, hands down. Sticky stuff as good as hydrogel, and its a bitch to take off- youll wax a dude. Only in an extremely manly way, of course.

The landmark for the mid axillary intercostal (4th) space underneath the armpit is money for a couple reasons- 1, your kit doesnt cover there, and you can get to it quickly without removing gear (specifically for the example of TX in a less than friendly environment where removing a chest rig is less than ideal), 2- it's very, very simple. So simple I taught every one of my Rangers that specific technique- and that is NOT a dig on Rangers, I'm using them as an example of "not very medically trained dudes doing a somewhat advanced med procedure". 3- You avoid the ole "what if im too medial and puncture the pericardium and/or heart?" debate. IMO, thats some nonsense, but yea.

Other points- you arent going to hear a whoosh. Seriously. the number one indication of correct placement and relief of a PTHX is patient presentation, specifically O2 sat and patient relief. Crip/DOC/smarter med dudes, correct me if I am wrong. and the 3.5in 14G catheter is my standard for needle D- and hub that mother effer. Seriously, put it to the hilt. With correct placement you will do nothing wrong.

I would like to disagree with the chest tube- we (PJ's) are trained, I have performed them on live patients, they have their place- but not in the field. Life or death, sitting on a pt. for hours at a time with no hope of higher care? i would STILL shy away from this procedure. The risk of infection post event, complexity of the actual procedure, and ability of operator to sedate/administer pain meds adequate to make it happen for the operator are all considerations that should be taken very, very seriously. Also, MOI is most certainly an indication for a "diagnostic" needle decompression. PT complains of shortness of breath and the MOI is indicitave of CX trauma to include blast/percussion- dart em up kid.

Thats just me. Re-attacks?


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## txpj007 (Mar 11, 2011)

amlove21 said:


> Im gonna co-sign on some stuff here- if you dont have any experience with the HALO, you are using an inferior product. No kidding, that is the best chest seal on the market, hands down. Sticky stuff as good as hydrogel, and its a bitch to take off- youll wax a dude. Only in an extremely manly way, of course.
> 
> The landmark for the mid axillary intercostal (4th) space underneath the armpit is money for a couple reasons- 1, your kit doesnt cover there, and you can get to it quickly without removing gear (specifically for the example of TX in a less than friendly environment where removing a chest rig is less than ideal), 2- it's very, very simple. So simple I taught every one of my Rangers that specific technique- and that is NOT a dig on Rangers, I'm using them as an example of "not very medically trained dudes doing a somewhat advanced med procedure". 3- You avoid the ole "what if im too medial and puncture the pericardium and/or heart?" debate. IMO, thats some nonsense, but yea.
> 
> ...


No re-attacks here bro...you're spot on.  I'm really gonna have to start posting when I have time to spell it all out as well you and not between smoke sessions with my quick to the point mildly sarcastic manner.


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## TLDR20 (Mar 11, 2011)

txpj007 said:


> No re-attacks here bro...you're spot on. I'm really gonna have to start posting when I have time to spell it all out as well you and not between smoke sessions with my quick to the point mildly sarcastic manner.




The whole woosh thing was a sarcastic post, it was one of my first posts here before I had learned the sarcasm of the internet. I don't want to come across as if I was saying that as a real diagnostic tool.


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## pardus (Mar 11, 2011)

txpj007 said:


> Have to concur with the HALO they do stick to anything and do work well.  The ACS where a great idea but ive never been able to get them to stick or stay in place with blood and sweat...ever. One more tip so i can feel like im smart.  A quick way to find your landmark for a needle D is to put your hand  in the pt's armpit (the same way you did when you were a kid making fart noises in school with your hand...lol...thats the best way i can describe it without a picture) and your thumb should line up pretty damn close to mid clavicular 2IC.  Works well with big chested guys when its hard to palpate.



I have no Idea what a HALO is. The Hyfin is (was) the standard (at my level) the last I heard, The ACS was declared a no go a couple of years ago due to it not sticking to blood etc...

The alternate site (not mid clavicular) for a NCD is lateral under the arm pit, four fingers down from the arm pit, small word lol.

Wooshing etc... aside, would the Pt's breathing/comfort level be an immediate indicator of successful needle placement?


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## TLDR20 (Mar 12, 2011)

pardus said:


> Wooshing etc... aside, would the Pt's breathing/comfort level be an immediate indicator of successful needle placement?



Yes


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## pardus (Mar 12, 2011)

Thanks.


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## surgicalcric (Mar 12, 2011)

pardus said:


> ...The alternate site (not mid clavicular) for a NCD is lateral under the arm pit, four fingers down from the arm pit, small word lol.


Mid/Anterior Axillary line is the word(s) you are are looking for in that description.

HALOs are good seals as are Bolins but I am a Hyfin fan myself...  The Asherman still sucks ass even with new glue; stay away from them.  In fact guys would do better to use 100mph tape and the ACS packaging for an occlusive dressing...

Crip


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## pardus (Mar 12, 2011)

surgicalcric said:


> Mid/Anterior Axillary line is the word(s) you are are looking for in that description.
> 
> HALOs are good seals as are Bolins but I am a Hyfin fan myself...  The Asherman still sucks ass even with new glue; stay away from them.  In fact guys would do better to use 100mph tape and the ACS packaging for an occlusive dressing...
> 
> Crip



Thanks mate, I had a brain fart on that one.


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