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Prefered chest seal
Old 03-15-2009, 13:37   #1
crash
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Question Prefered chest seal

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.
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Old 03-15-2009, 13:50   #2
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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...
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Old 03-15-2009, 14:09   #3
swatsurgeon
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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
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Indication
Old 03-16-2009, 14:23   #4
rcm_18d
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Indication

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.
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Old 03-16-2009, 17:06   #5
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Quote:
Originally Posted by Surgicalcric View Post
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.
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Old 03-28-2009, 22:22   #6
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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.
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Old 03-29-2009, 12:07   #7
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Quote:
Originally Posted by rcm_18d View Post
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
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'Revel in action, translate perceptions into instant judgements, and these into actions that are irrevocable, monumentous and dreadful - all this with lightning speed, in conditions of great stress and in an environment of high tension:what is expected of "us" is the impossible, yet we deliver just that.
(adapted from: Sherwin B. Nuland, MD, surgeon and author: The Wisdom of the Body, 1997 )

Education is the anti-ignorance we all need to better treat our patients. ss, 2008.

The blade is so sharp that the incision is perfect. They don't realize they've been cut until they're out of the fight: A Surgeon Warrior. I use a knife to defend life and to save it. ss (aka traumadoc)
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Cx wound
Old 03-30-2009, 10:20   #8
rcm_18d
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Cx wound

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?
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Old 03-30-2009, 11:34   #9
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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 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.
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Seal it
Old 03-30-2009, 12:22   #10
rcm_18d
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Seal it

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?
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Old 03-30-2009, 13:08   #11
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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
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'Revel in action, translate perceptions into instant judgements, and these into actions that are irrevocable, monumentous and dreadful - all this with lightning speed, in conditions of great stress and in an environment of high tension:what is expected of "us" is the impossible, yet we deliver just that.
(adapted from: Sherwin B. Nuland, MD, surgeon and author: The Wisdom of the Body, 1997 )

Education is the anti-ignorance we all need to better treat our patients. ss, 2008.

The blade is so sharp that the incision is perfect. They don't realize they've been cut until they're out of the fight: A Surgeon Warrior. I use a knife to defend life and to save it. ss (aka traumadoc)
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Old 03-30-2009, 17:55   #12
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Question

Quote:
Originally Posted by swatsurgeon View Post
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?
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Last edited by crash; 03-30-2009 at 17:59. Reason: spelling.
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Old 03-30-2009, 18:39   #13
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Quote:
Originally Posted by swatsurgeon View Post
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

Last edited by Pacer; 05-09-2009 at 20:22. Reason: typos
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Old 05-04-2009, 11:00   #14
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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?
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Old 05-04-2009, 11:04   #15
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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
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