Remove the catheter from the needle, turn needle 90 degrees so the bevel is now facing left or right as opposed to upward and use on a 10-20 degree angle just as you would a scalpel. It takes a lil practice and isnt as fast as using a scalpel but it will work in a pinch.

Crip

Gentlemen,
I would like to focus briefly on the equipment used for an open (sucking) chest wound. Multipart answer here:
1)Has anyone dealt with a true open chest wound where there was free movement of air both in and out of the pleural space, and 2) used a 3 sided dressing or asherman type device. What was the result? Did the dressing or device prevent the need to provide positive pressure ventilation (BVM or ETT intubation, etc) and most importantly, was it a true open chest wound?
Ss

First on scene to a 32 y/o Female with multiple stab wounds to chest and back. PT is combative and bleeding profusely. Once we got PT into back of truck we exposed her and found a wound to left upper chest and neck just above sternal notch, with free air moving in and out of chest wound. PT complaining of having a hard time breathing. 3 side occlusive dressing placed. 2 large bore IV's placed. Fluid challenge with .9 NS started as she had no radials at the time. PT did say it was easier to breathe once we got dressing on. PT was maintaining her own airway at time. By the time we made it out of the apartment complex PT arrested. ACLS protocols followed on rest of way to trauma center. PT pronounced DOA at ER. Autopsy noted aorta and lung laceration. PT bled out before we could get her to OR.


Hope this helps.

JJ

2 torniquets (1 SOF, 1 CAT) carried on person and accessible

2 pr Nitrile Gloves
4 Alcohol swabs
4 Betadyne swabs
2 14 ga Catheters
4 Chest seals, self-adhesive
1 6" self-adhering ACE
1 4" self-adhering ACE
2 Z-Pak Gauze dressings
1 HemCon
1 Quiklot
1 Laminated 9-line card
1 Alcohol pen
1 Marker
Trauma shears (not to be used for hooch construction)

Yes. Too many infact, both in the ER and at EMS.


I have used ACS, defib pads, large tegaderms, and seran wrap.

Of the patients who were conscious, and maintaining their own airways, all claimed relief of the SOB, until pressure built up from the 4-sided dressings requiring a needle-drill.

Of the ones who were ETT'd, O2 sats was higher until pressure increased, resulting in venting becoming more difficult, indicating the need for a needle-drill.

Hope that answered your questions...

Crip

Surgcric,
You answered it perfectly.....IF and when a patient becomes symptomatic (non-intubated pt.), time for a 3 sided dressing/ACS, etc. All patients with positive pressure being applied via ETT or BVM, don't need one. A dressing somewhat reduces the future contamination (above and beyond what has already occured). The fact is that you have to watch these people like a hawk....if the open end is not letting go of the air, they get a tension PTX. I haven't found a reliable tape or adhesive that sticks well to the body when it is dirty, slimy from sweat, etc. I haven't tried duct tape but I will now to see if it holds.

Back to the original issue: what method works most reliably for these wounds?
So far multiple people have used different methods to seal the chest. Can we safely say there is no one standard? Any product that can form a barrier to the inflow of air and yet release it when necessary would seem to work......
$15 for an ACS, <$1 for saran wrap and duct tape and everything in between.

Needle decompression for tension PTX: need a needle that is 3-3.5 inches long, longer and placed in the incorrect place, you harpoon the heart or lung potentially. How many to carry on your self??? I say 5. They bend too easily and repeat decompressions are >60-70% likely. Little weight and little size, so more is better. My record was 7 in one side....he lived to the hospital.

Prep pads: alcohol and betadine....why both? Needed at all? Do they sterilize the skin or just act as a method to wipe away some of the grime?

more to follow.

ss

Well lets see if I can convey my thought this afternoon while medicated...
 

I really have used everything from the ACS to moleskin to saran wrap. Also to be honest I was never impressed with the one way valves (as they seemed to fail once blood worked its way into the flutter valve) or with the function of the 3-sided occlusive dressing for the same reason. I cant begin to tell you the number of studies I have read which argue back and forth on whether the 3 sided or 4 sided occlusive dressing is the Gold Standard" for the initial treatment of penetrating trauma to the thorax. Quite frankly I don't really see what the fuss is all about. I understand the theory behind the 3-sided/valved dressings but again have never seen them work very well, OMMV. With either, close attention needs to be paid to the patients respiratory status, for changes signaling a tension PTX, as you mentioned above.

As for adhesive, I have never been that impressed with COTS solutions with the exception of the Hyfin Chest seal (which has an adhesive akin to that on the old ekg pads or moleskin which will take skin and all when removed) however I havent used one on a real patient yet and have only tested the adhesive on a water soaked patient. (More to follow on this as I get back to my civilian job.) The ACS sucks; the BCS seems better but not a 100% solution; saran and duct tape work damn near 100% of the time but causes some obvious skin irritation due to the strength of the adhesive; Defib pads work but who carries them in the field; and large tegaderms / opsites work great due to the material being very flexible. No scientific data to support any of that though, just trial and error.

I agree about the caths, however the caveat being, shorter (2-2.5") will work if you move your site from 2nd ICS MCL to 5th ICS MAL. The bending is spot on with my experiences as well SS and as such one needs to prepare for that. I think my record was 5... I dont know about carrying that many in a BOK, but am not opposed to the idea but would like more discussion on it before I would try to convince my guys to carry more than 2 ea. Hopefully by ythe time someone has drilled someone twice there would be someone else around (the 18D or if working without a medic someone else) with a aidbag or CLS type bag which is over stocked with extra's of the commonly used items...

I generally just use alcohol to wipe the site clean moreso than trying to sterilize the site itself... I think most providers (emt's, nurses, MD's) do it because they were taught it was the right thing to do and it becomes muscle memory with everything else (iv sticks, injections, etc...) I dont see why we worry about it in a combat setting or the ER for that matter. If the patient has an open chest wound anything foreign micro that can get in got in through the larger hole the foreign object made on its path into the thoracic cavity. The patient will be receiving the antimicrobial of choice once at "bright lights and cold steel" anyways. Not attempting to promote bad medicine or that teaching to cleanse the site is wrong but in the scheme of things its not an issue... If that makes sense...

Enough of me babbling...

Crip

Crip,
The issue with decompressing in a lower spce is that with your "muscle memory" if you use or are handed a longer catheter, the risk of a cardiac puncture in the 4th, 5th, 6th interspace increases significantly. I have operated one 2 patients with this issue in the recent past. One had a tamponade and one had an arterial line...thankfully the medic realized it and capped it rather than pulling it out. Hit the left ventricle with a 5 or 7 inch angiocath (hence harpoon). Cook catheter co. Makes a 3.5 inch wire wrapped cath that can't bend or kink in 12 gauge. They double as a needle cric but I use them for the chest. Here is a multipurpose item, which is where I'm trying to go with all kit items.
As far as the skin prep, we remove all field placed lines within 24 hrs anyway, no sterility in the field.
ss

SS:

Thanks for the reminder of the hazards associated wtih decompressions in the MAL with longer caths. While on that subject, have you noticed any such inadvertent punctures using shorter caths or is it all based on the longer versions? Just curious.

As for multiple purpose items I am all for it. I am a firm believer in the more educated we are the less we need to carry.

Keep the ideas coming.

Crip

I have only seen one cardiac injury with a 2.5 inch needle placed parasternally, 7th space and got the heart.

Parasternally... Havent seen nor heard of that method before. Think I may just leave that one out of the toolbox...

Crip

Ok, moving on in the IFAK, the tape. We discussed the idea of Duct tape, which is nice, but has anyone really looked at the difference in effectiveness between that and Kendal's 2” Wet-Pruf? We use the 1” to secure ET tubes and after a quick wipe it will stick reliably to the face despite saliva and mixed gastric contents. Combine it with a tincture of benzoin swab and that tube is there for the duration. Has anybody used it for dressings?

What's the per foot cost difference between duct tape and waterproof medical tape?

I guess it depends how you come to obtain the medical tape....:D
What tape do I have access to that is waterproof???? I don't think any of them are.
ss

I sit corrected--water resistant, rather than water proof. I rather expected that the Wet-Pruf tape Merlin mentioned was much more expensive than duct tape, with little difference in performance, thus giving the edge to duct tape for those of us without access to Class 8 Welfare :D.