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crash
03-15-2009, 13:37
We currently use the Asheman chest seal, which I've never been a fan of.

What have your expericens been with the below products, which do you prefer?


W/ One way valves
Bolin Chest Seal NSN: 6510-01-549-0939
Asherman Chest Seal NSN: 6510-01-408-1920
Emergency Chest Seal (tqsresponce .com)

W/O one way valve
Wound Seal NSN: 6510-01-562-3346
Hyfin Chest Seal NSN: 6515-01-532-8019
H and H Wound Seal NSN: 6510-01-562-3346

Are their others? (other than field expediant)

In my experience the ashermans have been flimsy and never want to stick to anything. Played with a Bolin awhile back and liked it, we've ordered a few to test out.

Have not used the wound seal; but have used the Hyfin seals and was impressed with their stickyness.

Surgicalcric
03-15-2009, 13:50
I like the Hyphin seals for their adhesiveness and the Bolin is in second place. Never really cared for the ACS. It is a good concept but the adhesive just doesnt cut the mustard.

Defib pads work great too...

swatsurgeon
03-15-2009, 14:09
time to throw a wrench into the mix:

What is the indication to apply a chest seal....BE SPECIFIC, and back up your answer with an explanation. (Time we all learn some facts rather than fiction)

ss

rcm_18d
03-16-2009, 14:23
The indications for a chest seal is any penetrating wound from the clavicles’ to the belly button on any of the four sides of the chest (front, back, and armpits). This is conducted after Situation(winning the fight), Major bleeding, and Airway are addressed. This would be considered a chest wound because it is never clear where the patient was in his or her respiratory drive when the injury occurred. The intent is to stop any air going into the pleural space from the outside. The purpose of the three sided dressings (i.e. Asherman, Bolin, or Emergency Chest Seal by Asherman) is to allow air to escape if it can, to prevent the development of a Tension Pneumothorax. This is the second leading cause of preventable death on the battlefield.

crash
03-16-2009, 17:06
I like the Hyphin seals for their adhesiveness and the Bolin is in second place. Never really cared for the ACS. It is a good concept but the adhesive just doesnt cut the mustard.

Defib pads work great too...

Never thought about defib pads before, seems like it would work; don't usually have propaqs or the pads in the field.

18D4VRWB
03-28-2009, 22:22
I concur. Nice answer and we (18Ds/and or those taught) would be prepared for needle D which as now in TCCC requires two indications. MOI and difficulty breathing.

swatsurgeon
03-29-2009, 12:07
The indications for a chest seal is any penetrating wound from the clavicles’ to the belly button on any of the four sides of the chest (front, back, and armpits). This is conducted after Situation(winning the fight), Major bleeding, and Airway are addressed. This would be considered a chest wound because it is never clear where the patient was in his or her respiratory drive when the injury occurred. The intent is to stop any air going into the pleural space from the outside. The purpose of the three sided dressings (i.e. Asherman, Bolin, or Emergency Chest Seal by Asherman) is to allow air to escape if it can, to prevent the development of a Tension Pneumothorax. This is the second leading cause of preventable death on the battlefield.

Any penetrating wound....interesting. If there is free communication, lets say a hole the size of a silver dollar so that the lung is visible, is there a risk to an "open PTX"? What is the risk?
As far as air getting in and causing a tension PTX, there must be a way to trap the air in the chest cavity (refer to my first question). What is the scientific validity to a 3 way chest seal, has it been proven to be necessary on all chest wounds regardless of etiology, size, mechanism, patient status????

ss

rcm_18d
03-30-2009, 10:20
I see your point, “why seal a wound that is relieving itself.”

At the same time will a three sided dressing cause any further harm if emplaced correctly? If there is a path of least resistance scenario, air is entering faster than it is escaping, the absence of a dressing could potentially cause the lung to collapse faster than it would if it was treated. The lung may not be completely collapsed at the time of the treatment and could potentially have some remaining surface tension that allows some air exchange. This, in my opinion, is the reason it is universal to seal the chest from the outside with a one way valve. I personally feel that there is nothing wrong at all with sealing the cx completely, from a medic stance, but I carry many needles for decompression. The problem arises if the care is passed to another due to the tactical situation. The recognition of true, progressive shortness of breath, or difficulty breathing can be difficult to the untrained operator. We conduct an exercise for our students where they, carry a straw, and run 100m or so, as fast as they can, at the end of the run they plug their nose, breath through the straw, and look at their buddy. We try to explain that this is how a patient with difficulty breathing will present. The three sided dressings are the dressing of choice for the lowest common denominator. Most of the time the first responder will not be a medic and it is the KISS (Keep It Simple Stupid) principle that calls for one dressing to treat any penetrating cx wound. I personally carry patches of HydroGel and really like the Hyfin. Defib pads are good as well but the difference in manufactures can very the effectiveness. The development of tension normally takes some time and a needle decompression is very fast, easy, and effective. What are your thoughts on a cx tube for extreme circumstances?

RichL025
03-30-2009, 11:34
Jumping in with my perspective here. Former 18D, now a surgery resident.

If someone has a quarter-sized hole in their flippin' chest and you're staring at lung, you had better be sealing it, unless you want a physiology experiment on single lung ventilation.

If by converting an open pnemothorax into a closed you create a tension, well, as a 11B basic trainee 22 years ago I was taught to "burp" the wound ... an extensive literature search on my part has failed to reveal any evidence supporting this practice :rolleyes: but if you have someone not trained to perform a needle or chest tube that's better than nothing of course. You are directly addressing the pathology involved.

Although I have to believe that enough pressure to develop tension physiology would tend to pop the clot out of the wound anyway. Maybe not.

In answer to the previous question, yes to a chest tube. The only question is where to place it - in the field or can your patient wait until he gets to a nice clean medical facility?

I've been in med school and residency for the entire duration of this last conflict, so I'm not sure my input on where to place the tube is valid. If you know you only have a short flight to a CSH or FST, and you'll have someone who knows what they're doing watching your patient, then you could probably wait on the chest tube. Unsure evacuation time, mass casualties, etc then I would put one in before evac... but again, let me caveat that my field medic experience is a bit distant.

rcm_18d
03-30-2009, 12:22
I agree that any cx wound is to be sealed, period!

I am merely an 18D(No Doc), and would like all the docs' perspective on when a cx tube should be performed in the field. My current thoughts on this, is when a needle decompression is a recurring event due to blood filling the pleural space and/or massive lung damage. Obviously the duration to further medical care is a huge one, but I understand this criteria. In the case of blood filling the space, I feel that it is a doubled edge sword. I feel it should be performed in conjunction with positive pressure ventilation to maintain some pressure on the lung to somewhat tamponade the bleeding. If it is a patient I will have to sit on for a while, the blood loss needs to be closely monitored, and blood is needed. This is one of the times for a rapid sequence induction, but that has it’s adverse effects as well. A cx tube alone could cause the loss of more blood than life can sustain. Once this sequence is begun the medic will most likely be tied to this patient for obvious reasons. A pleural vac will most likely not be available. Understand I have given chest tubes and I understand how quick and easy they are, but never in the field. Location is 5th ICS MAL. Any thoughts?

swatsurgeon
03-30-2009, 13:08
remember, sealing was created for the least educated providing care in the field. This discussion was really for academic purposes. If you seal the wound and didn't need to, okay, if you sealed the wound and it did need it, okay.....not enough training "across the board" to allow people to make that decision all of the time undar all circumstances, i.e., basic medic, typically not talking about docs or 18D's with a greater fund of knowledge.
An open wound BTW is a safe wound just like a 'simple' PTX....air exchanges and based on negative pressure ventilation (our usual method of breathing) vast majority of patients will do fine....if any problems, BVM or intubate and provide positive pressure ventilation then the open chest is a100% non-issue.
Controlling contamination is another but related issue.
ss

crash
03-30-2009, 17:55
An open wound BTW is a safe wound just like a 'simple' PTX....air exchanges and based on negative pressure ventilation (our usual method of breathing) vast majority of patients will do fine....if any problems, BVM or intubate and provide positive pressure ventilation then the open chest is a100% non-issue.
Controlling contamination is another but related issue.
ss

By sealing the wound you give it the chance to build pressure and become a pneumothorax; but wouldn't using a chest seal with a one way valve prevent pressure from building?

Preventing outside air from coming in, would allow for negative pressure in the chest when the diaphragm contracts, which the lungs need to inflate/pull ambient air in. If you leave the wound open when the diaphragm contracts wouldn't it just pull ambient air into the plural space through the wound instead of into the lungs?

With air pressure around the lung the same as the ambient, wouldn't positive pressure ventilation be necessary?

Also what are your thoughts on keeping the wound clean if left open? Wrap loosely with kerlix, keeping debris out while still allowing air to pass through?

Pacer
03-30-2009, 18:39
An open wound BTW is a safe wound just like a 'simple' PTX....air exchanges and based on negative pressure ventilation (our usual method of breathing) vast majority of patients will do fine....if any problems, BVM or intubate and provide positive pressure ventilation then the open chest is a100% non-issue.
Controlling contamination is another but related issue.
ss


I'm going to go out on a limb here, and amplify/ expound just a little, as a NON THORACIC NON Surgeon.

I believe the concept of negative vs positive pressure ventilation is germane here. A physiology experiment/ analysis of formula, etc, suggest (note the language) that a chest wall defect that is continuously communicating (ie you can see lung or space) with a cross sectional area (Pi R squared) > 2/3 the same cross sectional area of the individals glottis will allow air to preferentially enter the chest wall (pleura) with NEGATIVE PRESSURE breathing (sucking, like all we humans do natively). While a simple Pneumothorax is often only mildly symptomatic in a sedate patient (dyspnea) and usually results in no hemodynamic effect other that hypoxemia (single lung ventilation, no time for physiologic compensation).

Note that many penetrating wounds (lo velocity, pistol or knife/ice pick) will self seal the chest wall as the tissue planes slide depending on the position of the arms, torso etc.

Just like a flail chest, where the chest wall segment compromises the negative thoracic pressure if large enough, POSITIVE PRESSURE VENTILATION (bag valve mask/intubation and ventilator) temporizes /treats the problem, but is less practical in a care under fire, mass casualty, disaster triage type environment (or cave rescue, mountain SAR without evac capacity).

A 'seal of choice" in the Hospital environment with adequate monitoring personnel is typically either to stuff it /over it with vaseline guaze, (later repair by the surgeon)

A tension pneumothorax (with very different hemodynamic consequences when the heart shifts and "crimps" the IVC/SVC) will only develop if gas can escape into the space (typically from the lung or bronchus) and cannot escape. Unfortunately, in high velocity GSW, explosive /IED,etc, or Hilar injuries, or under Blast overpressure/POSITIVE PRESSURE BREATHING, explosive decompression, etc, we are PROVIDING the pressure to faciliate such communication. Thats why we "prefer' to decompress "expectantly' in Fixed Wing Air Evac, (altitude and baro pressures are more severe than rotocraft, thought the problem can happen there to), and our surgical colleques may find SOME chests that require multiple garden hose chest tubes (36 Fr) to high suction to successfully re-inflate a lung (bronch-pulmonary fistula).

The easiest way, I agree SWAT Surgeon, is to release the seal and rethink the solution. Takes training and decisonal capacity, as well as being willing to spin the OODA loop and near continuosly monitor the individual patient (hard to do when the unit has another mission, and mulitple patients)

I "trained" as an Emergency Physician, in a knife and gun trauma center, after being a medic. If a tension pneumothorax requires decompression, what do you use if there is no external chest wound? recent Journal of trauma article challenges our "logic" and expediency, as a human study yield both inadequacies and complications from the "5 cm " (2 in) Jelco.

That's why the Trauma Surgeon (via ATLS) will usually dissect the tract for the chest tube, and stick a finger in there to make sure s/he is in the chest (and not the liver/stomach...) Air services might choose to use a "McSwain dart", though as a blind percutaneous "brutane" maneuver, has the same complications as the Jelco (IV Needle")

Just some thoughts.

Thanks for listening

B

Churchill_MD
05-04-2009, 11:00
Recently a friend of mine told me that the TCCC guidelines encourage/warrant the use of Hyfin Chest Seal instead of Asherman Chest Seal? Is this true?

Another thing that he told me is that whenever applying Hyfin one must/should puncture the chest wall with the needle and leave it in place in order to be prepared for tension PTX in advance. Is this also true?

The Reaper
05-04-2009, 11:04
Churchill:

You might want to go back and review the rules for posting on this site. You seem to be missing something.

Please do not post again till you have.

Thank you.

TR

afo417
05-09-2009, 18:09
I just want to say thanks for allowing me on this site. I have been a member for about 5 months. By reading these posts I learn so much and it refreshes my memory. I don't get to use my "skills" often, and so far, thank God, haven't had to treat a gsw or knife wound to the chest.

rcm_18d
05-14-2009, 17:43
The new generation of Asherman Chest seals have been sticking very well. I am sure there are some of the old ones still floating around though. The Rangers we taught last week said they have been having problems with the Hyfin dressings. They said after time the hydrogel or sticky stuff has been adhering to the package that the dressing comes in. They said the manufacture is changing the packaging to the tinfoil type like the old petroleum gauze. I have also heard that the MARSOC guys are not carrying the defib pads for chest dressings anymore due to the multitude of manufactures. The contract office never gets the right stuff especially if there are multiple options. There are some other reasons I just haven't gotten the whole story. If hydrogel didn't cost so damn much the answer would be easy! The bolin is what the Navy carries but I am not sold on it.

SwedeGlocker
05-16-2009, 00:06
Cheap Hydrogel chest seal = PMI Halo seal

SFWPNSSGT/SPC
06-10-2009, 08:17
My $.02: Not a QP, but I really like my job.
With the limited experience I have with the Bolin, I like it. The ACS is great if you have the time to make sure it sticks. The Hyfin sticks well and is more durable, but no one way valve. Need to get a hold of some bigger sizes. The survivability of the packaging varies. I have not had any Bolin fail yet when I test them after coming out of the bag, but I change my ACS out every 3 or 4 months because they get beat up and stick to their backing. Same problem with the Hyfin; one bag was exposed to some extreme heat though.
I've covered all open chest injuries because I was never in a very clean environment. Also, I have not learned any techniques to manage large holes in the chest without covering them or how to recognize the complications during monitoring other than the basics. Didn't feel comfortable with it. The first time I saw a lung, the only thing I could think about was covering it up, and getting them out of my house. While in Afghanistan I ran into some shrapnel injuries on locals by VBIED (3 MASCAL, and assorted other patients). It was never just one hole. I would use a combination of Hyfin and large Tagaderm with tape, and an ACS for the bigger holes that looked to be transferring air. If the wounds were bleeding in any troubling amount I used xeroform gauze and gauze pads over that, tape, sometimes an Israeli. I would worry about the NCD later. This was all in a small aid station setting. I had 7-10 great TCCC guys at a time and sometimes CANMIL medics. All the guys worked on these methods, and executed flawlessly. Another way I used the Asherman was on needle chest decompressions. I would place the ACS over the hub to secure it, and to provide a one way valve (someone told me this was not beneficial. True?) I know in a field setting it's not always an option, but all of these dressings worked if the surface was prepped. I ended up using disposable razors, tincture of benzoine, Dermabond and tape on a clean chest wall. They got to me 10-20 minutes after the explosion. I kept some for up to 12 hours. Couldn't always get them all out to KAF, some ended up making it to Pak in the back of trucks (thanks to a great Afghan Commander). The dressings worked while I had them, and I heard that the combinations of dressings worked on the way to the PAK hospitals.

Doczilla
06-12-2009, 23:23
I agree that any cx wound is to be sealed, period!

I am merely an 18D(No Doc), and would like all the docs' perspective on when a cx tube should be performed in the field. My current thoughts on this, is when a needle decompression is a recurring event due to blood filling the pleural space and/or massive lung damage. Obviously the duration to further medical care is a huge one, but I understand this criteria. In the case of blood filling the space, I feel that it is a doubled edge sword. I feel it should be performed in conjunction with positive pressure ventilation to maintain some pressure on the lung to somewhat tamponade the bleeding. If it is a patient I will have to sit on for a while, the blood loss needs to be closely monitored, and blood is needed. This is one of the times for a rapid sequence induction, but that has it’s adverse effects as well. A cx tube alone could cause the loss of more blood than life can sustain. Once this sequence is begun the medic will most likely be tied to this patient for obvious reasons. A pleural vac will most likely not be available. Understand I have given chest tubes and I understand how quick and easy they are, but never in the field. Location is 5th ICS MAL. Any thoughts?

Much of this depends on the environment of the procedure, and how well you think you could preserve a sterile field. I don't think a sterile field is necessary in all situations. If you can do it, great. You'll have to balance the need for the chest tube against the risk of infection. The decision is more complex in the field than it is in the hospital due to the contamination issue that you bring up.

The short of it is, if you had to decompress them once, you will have to do it again. Therefore, the patient will require close monitoring no matter what, again tying up the provider to watch for reaccumulation of the tPTX. If the chest tube is in, then the PTX cannot build up under pressure to become a tension ptx. Even without a pleurevac, this applies.

If a patient is under positive pressure ventilation and you had to decompress, I would place a chest tube. A pleurevac is not really needed in this case, since the PPV will expand the lung sufficiently, and the CxT can be left open to air. This essentially creates an open PTX as SS discussed. A corollary: any patient on PPV with increasing vent pressures or difficulty bagging should be decompressed and have CxT placed.

For the patient in extremis, with impending cardiopulmonary arrest, I would place the chest tubes, even with no sterile equipment. Intubate them, place the tubes, and if you have neither the time nor the means to secure a drainage system, leave them open to air. If a chest tube is not immediately available, standard endotracheal tubes will suffice and can be placed in much the same manner as the CxT.

For a patient breathing on their own, a CxT without a flutter valve or pleurevac will essentially inactivate the affected lung, since the patient will not be able to create sufficient negative pressure in the chest to move enough air. This could potentially significantly increase the patient's work of breathing. If you recognize the need for a CxT in this setting and do not have the ability to manufacture an improvised pleurevac, then I would strongly consider intubating the patient for PPV.

Another consideration is if the patient with a simple PTX will undergo transport by air with significant altitude change, a CxT may be in order to prevent a simple PTX from becoming a tension PTX (although bringing them down in altitude makes this less likely than going up). The problem with air transport is that it is very difficult in that environment to auscultate for asymmetric lung sounds, so the flight medic/doc has to monitor other indications of tPTX. With our attention to hypothermia, stripping layers away from a patient to assess them is difficult and potentially hazardous to the patient. Worse yet, these indicators of PTX may go unnoticed. With a) a history of chest decompression, b) chest trauma, or c) respiratory difficulty after a blast injury, I would consider placement of a CxT prophylactically if transport will be longer than a few minutes.

If there is significant blood loss into the chest, and if you have a sterile drainage system with your chest tube, you may be able to autotransfuse the lost blood through a blood needle back into the patient. This is obviously more difficult through an improvised system, but still possible. And the patient's own blood cannot be improved upon as a resuscitation fluid.

I have never attended 18D training, so I don't know if any of the above is new information for anyone here. I'm not sure if this is what you were looking for, but I hope it helps.

'zilla

ACE844
06-13-2009, 21:08
"Doczilla,"

I was wondering if you guys 'in the field' (FEBA-FOB-wherever) used THESE (http://www.buyemp.com/product/1021317.html) at all?

In at least one of the scenarios above I could see where this may be a great adjunctive therapeutic tool to have available for these instances.

Whiplash
10-21-2012, 21:35
HALO chest seals are just as good if not better than the hyfins, plus they come with two seals in a package

swatsurgeon
10-22-2012, 12:22
HALO makes a good seal, I like it...it does as advertised and sticks; you can repeatedly 'burp' it and it continues to stick. Good size and 2/pkg make it better. We got them for our SWAT team to carry with their TQ and combat gauze and all of the guys have been trained on its proper use. Doesn't take a rocket scientist (or neurosurgeon) to be able to use one correctly and did I mention they stick to a bloody chest wall.......

ss

LeakyBandage
05-13-2014, 13:53
Now that a vented seal is the first choice dressing (https://www.jsomonline.org/TCCC/TCCC%20Change%20Prop%201302%20Open%20Pneumo%20Rx%2 0130613%20Final.pdf) per TCCC, which brand of chest seal products are you guys seeing and/or recommend: SAM, HALO, HyFin, etc? In my research I have read that the current crop of vented seals are all acceptably effective regarding venting, but their adhesion in tough environments varies.

Brush Okie
05-13-2014, 16:10
Now that a vented seal is the first choice dressing (https://www.jsomonline.org/TCCC/TCCC%20Change%20Prop%201302%20Open%20Pneumo%20Rx%2 0130613%20Final.pdf) per TCCC, which brand of chest seal products are you guys seeing and/or recommend: SAM, HALO, HyFin, etc? In my research I have read that the current crop of vented seals are all acceptably effective regarding venting, but their adhesion in tough environments varies.

Duct tape and a plastic MRE bag work very well. It is the skill of the person more than the bandage its self. The problem with ANYTHING sticking is the person many times is covered in blood and or sweat from shock. you can dry them off then use the little ampules of sticky skin prep stuff for using steri strips. (cant remember name)

The Reaper
05-13-2014, 17:16
Duct tape and a plastic MRE bag work very well. It is the skill of the person more than the bandage its self. The problem with ANYTHING sticking is the person many times is covered in blood and or sweat from shock. you can dry them off then use the little ampules of sticky skin prep stuff for using steri strips. (cant remember name)

Tincture of Benzoin.

Burns like a MF when injected into a blister.

TR

Brush Okie
05-13-2014, 17:19
Tincture of Benzoin.

Burns like a MF when injected into a blister.

TR
That's it thanks. My memory is gone to crap lately.

Barbarian
05-15-2014, 08:14
Tincture of Benzoin.

Burns like a MF when injected into a blister.

TR

Is that an effective treatment for a blister, or is it simply cheap entertainment?

Odin21
12-02-2014, 20:01
The aid station I was at for a while kept a roll of "breacher's tape" to use for chest seals. Thankfully while I was there we never had to use it, but the SF medics swore that it was the best chest seal ever made. Supposedly it would almost remove skin when it was removed but it would stick to anything wet as it was designed to be able to attach explosives underwater, hold them on doors, etc. As I recall, it was about 12in wide and several feet long of the stickiest plastic tape I have ever messed with in my life. I was just a support 68W but supposedly it works very well.