Field Tx of Pneumothorax

HoosierAnnie

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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)
 

Ajax

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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?
 

Ajax

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

surgicalcric

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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
 

Ajax

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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?)
 

HoosierAnnie

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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.
 

surgicalcric

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...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
 

Muppet

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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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