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Old 06-13-2008, 16:11   #37
Quiet Professional
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Join Date: Jan 2004
Location: Wherever my ruck finds itself
Posts: 2,972
Well lets see if I can convey my thought this afternoon while medicated...

Originally Posted by swatsurgeon View Post
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.
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.

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...
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.

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.
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...

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?
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...

"It's better to die on your feet than live on your knees."

"Its not who I am underneath, but what I do that defines me" -Batman

"There are no obstacles, only opportunities for excellence."- NousDefionsDoc

Last edited by Surgicalcric; 06-13-2008 at 22:04.
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