Tactical combat casualty care ( TCCC )
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medicineman
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AM,
The SCOMR on CCC came to that conclusion - it came up during the writing board this past week for the TCCC course. The trauma surgeon with us basically said that if the hole is less than 2/3 the size of the trachea, a one way valve isn`t needed. We were trying to figure out what, if any protocol the TCCC providers are going to get if a repeat insertion is required.
MM
The SCOMR on CCC came to that conclusion - it came up during the writing board this past week for the TCCC course. The trauma surgeon with us basically said that if the hole is less than 2/3 the size of the trachea, a one way valve isn`t needed. We were trying to figure out what, if any protocol the TCCC providers are going to get if a repeat insertion is required.
MM
Depends on the gear they are using I guess. If you're using the big cook cath, it probably wont kink, but the 14 gauge angiocath is prone to kinking, especially if they are getting moved around a lot. If you're strapped for gear, you can needle them, remove it, cap it and tape it to their chest. Then you can use it again on the same casualty.
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The up side to the cath getting kinked off is that as the lung expands to kink off the cath, the cath is no longer required. It is the pressure of the lung itself that does the bending.
If the lung colapes again then you will have to re-needle anyways.
Due to this and the small internal lumen of the cathlon, a heimlich valve is not usualy indicated. It won't hurt to put one on but I would not shed tears if it is not in place.
If the lung colapes again then you will have to re-needle anyways.
Due to this and the small internal lumen of the cathlon, a heimlich valve is not usualy indicated. It won't hurt to put one on but I would not shed tears if it is not in place.
medicineman
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Due to this and the small internal lumen of the cathlon, a heimlich valve is not usualy indicated. It won't hurt to put one on but I would not shed tears if it is not in place.
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Again - back to the KISS principle. I do remember when I was a baby medic a hundred odd years ago when we had to do the combat medical techniques courses in the field ambs, the old CFP 313-7 (Combat Medical Techniques for Medical Assistants) actually advocated inserting a chest tube (with Heimlich valve attached) directly into large GSW's to the chest. After going through this TCCC board, it's made me want to dig around to find my old copy and compare how different things were then and now - and it's not really alot FWIC.
MM
[/quote]
Again - back to the KISS principle. I do remember when I was a baby medic a hundred odd years ago when we had to do the combat medical techniques courses in the field ambs, the old CFP 313-7 (Combat Medical Techniques for Medical Assistants) actually advocated inserting a chest tube (with Heimlich valve attached) directly into large GSW's to the chest. After going through this TCCC board, it's made me want to dig around to find my old copy and compare how different things were then and now - and it's not really alot FWIC.
MM
Chest tubes are an interesting skill to push that far forward. I definitely think they have their place in special operations, even domestic SAR operations (were's gulley?). The Israeli's did a study that found that when doctors placed chest tubes in the field, i.e. battlefield, they were more often than not misplace, as in subcutaneously. Not sure how you can screw that up. Must have been the stress. You can use an ET tube in a pinch too. Needle is best for shorter evacs and has the advantage of being able to be pushed to the soldier level. I'm not sure if a chest tube would make a big difference at a medic level unless they are operating far and away. Chest tubes are great if you are isolated or far away. Remember though, this guy needs a hospital. That tube needs suction, it's easily dislodged if they are not in a controled environment, very painful and a big entry port for infection (especially in the desert). Remember even when you needle a chest, you've commited that guy to a chest tube.
By inserting a chest tube into the GSW do you mean a needle or a tube? A tube is pretty big to get in a GSW. And it will not necessarily be in the optimal place for tube placement.
Having said all that, its a good tool in the box.
By inserting a chest tube into the GSW do you mean a needle or a tube? A tube is pretty big to get in a GSW. And it will not necessarily be in the optimal place for tube placement.
Having said all that, its a good tool in the box.
Its interesting to watch the way tactical medicine is evolving. As we move away from invasion strategies and more into occupation strategies, we are seeing subtle injury pattern changes and considerable increases in efficiency and improvement in quality of TCCC resources. CASEVAC's are becoming so fast and relying on ground more than air. This is due primarily to the increase in FOB's, a larger footprint and more saturating presence and again a build up of resources over time. Instead of waiting for a helicopter, casualties are occuring closer to bases, helo's are taking to long to crank up and get out there, it's faster to "load and go" (where have I heard that before?) The poor PJ's are getting bored sitting on their duffs.
What this is causing is less medic time with the casulaty. For example medics aren't giving fluid because there is no time. I'm not saying this is a bad thing. This is good. Faster evac=decrease mortality.
TCCC when first came out was based largely on Viet Nam data with confirming data from Somolia, Gulf War 1 etc. They originally emphasized the unimportance of C-spine precautions with penetrating trauma. Whats happening now, with all these IED's going off and guys getting tossed around is more spinal injuries than they had originally been taught to be worried about. I think the future is going to see increasing due diligence WRT spinal precautions from IED blasts. Possibly a new guideline for spinal precautions in tactical environments. The old example of putting a collar on "Blackburn" in the middle of the street whilst rounds fly overhead - from Blackhawk down is obviously the argument against C-spine precaution in this environment. But the TCCC always advocated no precautions required for penetrating trauma. It said you will take al precautions for blunt trauma and if tacticaly feasible. I think that needs to be expanded and clarified for training sake to make it clear in everyones mind, and included in training to make soldiers and medics realize when to and when not to and exactly how to take spinal precautions in a tactical environment.
What this is causing is less medic time with the casulaty. For example medics aren't giving fluid because there is no time. I'm not saying this is a bad thing. This is good. Faster evac=decrease mortality.
TCCC when first came out was based largely on Viet Nam data with confirming data from Somolia, Gulf War 1 etc. They originally emphasized the unimportance of C-spine precautions with penetrating trauma. Whats happening now, with all these IED's going off and guys getting tossed around is more spinal injuries than they had originally been taught to be worried about. I think the future is going to see increasing due diligence WRT spinal precautions from IED blasts. Possibly a new guideline for spinal precautions in tactical environments. The old example of putting a collar on "Blackburn" in the middle of the street whilst rounds fly overhead - from Blackhawk down is obviously the argument against C-spine precaution in this environment. But the TCCC always advocated no precautions required for penetrating trauma. It said you will take al precautions for blunt trauma and if tacticaly feasible. I think that needs to be expanded and clarified for training sake to make it clear in everyones mind, and included in training to make soldiers and medics realize when to and when not to and exactly how to take spinal precautions in a tactical environment.
medicineman
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The guidline is reduced likelihood of need for spinal precautions with penetrating trauma - they still want you to think about it though, especially for blunt trauma. The chest tube deal I mentioned was in fact a tube - likely a smaller bore than you'd use if you were actually cutting the person open concerned, with a heimlich valve attached. SQ palcement - sounds like these guys were in a hurry and in the dark - literally. I could see it happening if they were going by feel for whatever reason.
On injury patterns, I remember reading an article in the Infantry Journal or ALLC Dispatches not many years ago that was talking about the Russian experience in Chechnya and the need to push medical units forward - like the Americans are doing in Iraq, as they were finding higher percentages of fatalities due to the close quarter fighting going on - enclosed space blast and fragmentation and close proximity to high velocity firearms were causing higher than expected mortality and morbidity rates.
MM
On injury patterns, I remember reading an article in the Infantry Journal or ALLC Dispatches not many years ago that was talking about the Russian experience in Chechnya and the need to push medical units forward - like the Americans are doing in Iraq, as they were finding higher percentages of fatalities due to the close quarter fighting going on - enclosed space blast and fragmentation and close proximity to high velocity firearms were causing higher than expected mortality and morbidity rates.
MM
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Hello,
I know that I am a little behind on this thread. However, the service that I work with uses the Cook Pneumothorax Kit. We don't use them
very often (about once a year) but when we do we find they work quite well. In fact, on can make their own with standard medical supplies (14G 3inch IV extension tubing, ect......keeps cost down rather than tossing exp. kit all the time....or if you are in a bind)
The last time we used one was a tension pneumothorax (obvious I guess ;D) from a MVA. A large pt. with lost of adipose tissue. The needle didn't become obstructed and air was aspirated. Also, compliance increased greatly (the two times that I have seen it done I have never heard that classic 'hiss').
The syringe is used to attach the one-way (the blue end in the picture above) valve to the tubing which in turn is attached to the cath. At least in our model....the tubing dose not fit on the end of the one-way valve.
So, I think the Cook set up and any modifications made to it meet the KISS principal.
Thank
D
I know that I am a little behind on this thread. However, the service that I work with uses the Cook Pneumothorax Kit. We don't use them
very often (about once a year) but when we do we find they work quite well. In fact, on can make their own with standard medical supplies (14G 3inch IV extension tubing, ect......keeps cost down rather than tossing exp. kit all the time....or if you are in a bind)
The last time we used one was a tension pneumothorax (obvious I guess ;D) from a MVA. A large pt. with lost of adipose tissue. The needle didn't become obstructed and air was aspirated. Also, compliance increased greatly (the two times that I have seen it done I have never heard that classic 'hiss').
The syringe is used to attach the one-way (the blue end in the picture above) valve to the tubing which in turn is attached to the cath. At least in our model....the tubing dose not fit on the end of the one-way valve.
So, I think the Cook set up and any modifications made to it meet the KISS principal.
Thank
D
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I with making the kits yourself because it is cheaper and all the materials are at hand.
Some people might argue weather or not a valve is indicated, and I think that depends on when you received your training. Most manuals still indicate it's use.
Myself, I have gone both ways. I just used just the needles during a PEA chest trauma. I think my reason was we were just around the corner from the hospital and I only had one of the kits made up. The second case was on a patient with a tension secondary to minor chest wall trauma. It was an interesting case. This guy was punched in the lower back during a fight which caused few broken ribs, which eventually caused the pneumo. It was almost missed as he didn't have a pneumo when he first walked into the nursing station and the staff was busy with an other patient who had a stab wound to the groin. We were there to medevac the guy with the stab wound. It was a venous bleed but the guy who held direct pressure for the hour it took us to get there should have got an award! All of a sudden it was like 'What about this guy?!'
He had all the classic symptoms of a tension pneumothorax except the tracheal deviation. The guy was a bit stressed out about the whole thing especially when he saw the needle but some pre-medication took care of that. It was kind of wild to stick this needle into the talking, breathing guy but still no hiss of air. I ended up sticking a one way valve on the needle as we had the time, the kit, and I was about to stick this guy on a plane.
So, I guess to sum up the two cases, I think I will keep sticking valves on if I have one and I have the time. That is until I track down some references that support that they are not required.
Some people might argue weather or not a valve is indicated, and I think that depends on when you received your training. Most manuals still indicate it's use.
Myself, I have gone both ways. I just used just the needles during a PEA chest trauma. I think my reason was we were just around the corner from the hospital and I only had one of the kits made up. The second case was on a patient with a tension secondary to minor chest wall trauma. It was an interesting case. This guy was punched in the lower back during a fight which caused few broken ribs, which eventually caused the pneumo. It was almost missed as he didn't have a pneumo when he first walked into the nursing station and the staff was busy with an other patient who had a stab wound to the groin. We were there to medevac the guy with the stab wound. It was a venous bleed but the guy who held direct pressure for the hour it took us to get there should have got an award! All of a sudden it was like 'What about this guy?!'
He had all the classic symptoms of a tension pneumothorax except the tracheal deviation. The guy was a bit stressed out about the whole thing especially when he saw the needle but some pre-medication took care of that. It was kind of wild to stick this needle into the talking, breathing guy but still no hiss of air. I ended up sticking a one way valve on the needle as we had the time, the kit, and I was about to stick this guy on a plane.
So, I guess to sum up the two cases, I think I will keep sticking valves on if I have one and I have the time. That is until I track down some references that support that they are not required.
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herseyjh said:
Tracheal deviation is only a sign of late, severe tension pnuemo. Often the pt will be beyond FUBAR by the time that sign is showing.
You should go off these indications for TCCC Needle decompression of the chest...(not for you, herseyjh, as I assume you already know this...but for everone else reading)
a chest or suspected chest injury with:
Difficulty breathing with
Deceased LOC and / or
No pulse at wrist
Heres my two cents:
You should differenciate between penetrating and blunt trauma, but still keep it simple.
Penetrating trauma to the chest and increased respiratoru distress - needle the side of the penetration and hope for the best, if that didnt work then trouble shoot it. Was it a bad needle or the wrong side? Careful about bi-lateral needles, you've just commited them to bi-lateral chest tubes which is not fun to manage.
Blunt trauma to the chest, increased respiratory distress AND disappearing radial pulse on inspiration, or altogether - then they get the needle on the affected side. Check carefully for asymetrical expansion and go for the side that isnt expanding.
In a tensio pneumo, it is not the collapsed lung that kills, it is the increased intrathoracic pressure that occludes the vena cava (big vein that returns all the bodies blood to the heart then lungs then heart then back to the rest of the body, for those less medically inclined). It's that decreased preload to the heart that causes the PEA (pulseless electrical activity) that casues death.
Beleive it or not its a blood issue, not a breathing issue.
Pericardial tamponade can mimic this, or any mediastinal pneumo or hemo. Here a needle wont do much, but nothing less than an ER really will. Same as a hemothorax, they need the surgeon.
You should differenciate between penetrating and blunt trauma, but still keep it simple.
Penetrating trauma to the chest and increased respiratoru distress - needle the side of the penetration and hope for the best, if that didnt work then trouble shoot it. Was it a bad needle or the wrong side? Careful about bi-lateral needles, you've just commited them to bi-lateral chest tubes which is not fun to manage.
Blunt trauma to the chest, increased respiratory distress AND disappearing radial pulse on inspiration, or altogether - then they get the needle on the affected side. Check carefully for asymetrical expansion and go for the side that isnt expanding.
In a tensio pneumo, it is not the collapsed lung that kills, it is the increased intrathoracic pressure that occludes the vena cava (big vein that returns all the bodies blood to the heart then lungs then heart then back to the rest of the body, for those less medically inclined). It's that decreased preload to the heart that causes the PEA (pulseless electrical activity) that casues death.
Beleive it or not its a blood issue, not a breathing issue.
Pericardial tamponade can mimic this, or any mediastinal pneumo or hemo. Here a needle wont do much, but nothing less than an ER really will. Same as a hemothorax, they need the surgeon.
medicineman
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From the TPWB, we are only going to be teaching needle decompression to TCCC providers for use in an open chest injury that degrades into a tension pneumo, not for closed ones. We tried, but were told N-O spells NO. Full stop.
Tracheal deviation is in fact a very late (nasty late at that) sign, though IF you have the time, stethoscope and amount of quiet needed (like, not on a battlefield !!), you can HEAR a mediastinal shift - I've had the occasion to hear complete transposition of heart sounds from left to right side with left sided pneumos without actually visualizing/feeling a deviation (spontaneous, walk in, 70% or greater collapse).
MM
Tracheal deviation is in fact a very late (nasty late at that) sign, though IF you have the time, stethoscope and amount of quiet needed (like, not on a battlefield !!), you can HEAR a mediastinal shift - I've had the occasion to hear complete transposition of heart sounds from left to right side with left sided pneumos without actually visualizing/feeling a deviation (spontaneous, walk in, 70% or greater collapse).
MM
medicineman said:
Do you mean "open" as only a sucking chest wound that seals itself and developes a tension. But then its not really "open" anymore and they couldnt touch it. Or do they close it themself and then it developes a tension, but then they can't needle it again because its closed again. By you saying only an "open" one kinda defeats the point of putting a needle in because there is already an opening in the chest.
What I am getting from this is you mean they are only treating pneumos secondary to penetration, not blunt trauma. This is reasonable when pushing such an invasive skill so far down. What about the medics? They should be given full range.
I have been told by both civi ER physicians, and even more emphatically by military surgeons to dart every decompensating chest injury. Our protocol states absence of breath sounds on one side, Resp rate 22 or more, o2 sat 92 or less gets one automatically. Apparently, the insult to the body is minimal ,and the improvement can be dramatic. I had one doctor speak to me for some time about pts in Iraq whose life had been saved by the porcupine approach to chest decompression. I guess it really would be more like an inside out porcupine. Basically keep darting until he feels better, obviously not in the absence of supporting the patient in all the other ways we can.
That's a big 10-4. As you know though, manytimes lifesaving interventions, ie the TK we're talking about elsewhere, have way too much emphasis on the downside complication, and not enough hype on the huge upside of saving your buddy. I'm sure you have heard the %10 chance of needle thoracentisis(sp?) causing pneumo. I say all the more reason to stick 2 in!
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JANES said:
For some reason the reply didn`t get posted so I`ll try again. What I`d written I thought was self expanatory, but apparently not. So, to clear the air, non-medical TCCC providers are going to be taught to dart tension pneumothoraces secondary only to penetrating trauma. As it stands, medics will continue doing what they`ve been trained to do.
MM
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Perhaps the reason for only allowing a needle thoracentesis on penetrating chest trauma is if there is a mis-diagnosis it is not all 'bad' as they might be getting a chest tube anyway.
If this, in fact, is the case it is a good compromise, as it opens this skill up to other providers while mitigating the chances of negative outcomes. People might not agree with me on this point, but I have noticed sometimes when you train people in new skills for a specific indication, people tend to look for that. In this case a tension penumothorax. You only have to see a few B/L chest decompression and a FAST stuck into their sternum to appreciate this.
As for medical providers I assume it is going to be open or closed chest wall injuries. This would be good, as from my experience, blunt closed chest trauma is the only patient population that I have seen tension pneumothorax in.
If this, in fact, is the case it is a good compromise, as it opens this skill up to other providers while mitigating the chances of negative outcomes. People might not agree with me on this point, but I have noticed sometimes when you train people in new skills for a specific indication, people tend to look for that. In this case a tension penumothorax. You only have to see a few B/L chest decompression and a FAST stuck into their sternum to appreciate this.
As for medical providers I assume it is going to be open or closed chest wall injuries. This would be good, as from my experience, blunt closed chest trauma is the only patient population that I have seen tension pneumothorax in.
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