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Needle Decompression Location Reviewed

We have discussed the changing thoughts regarding the sign and symptoms of Tension Pneumothorax in the past (see here: Rethinking Tension Pneumothorax). Although this study was broad, it did not address in detail the implications of different locations of one of the more popular treatments of tension pneumothorax: needle decompression. Due to an increased incidence of iatrogenic effects of improper needle placement, one of the recent topics of discussion among TCCC trainers has centered around locations (i.e., anterior vs lateral) of needle placement. Improper anterior placement in the mid-line direction can led to severe vascular injuries. Some have advocated for moving the primary location for needle insertion to the lateral location to mitigate iatrogenic effects. This location, however, raises other issues, specifically chest wall thickness in comparison to the anterior location, even as needles have increased in length.

A recent study published* in Academic Emergency Medicine seeks to answer one of the questions that have emerged from the debate by identifying the optimal site of needle insertion with respect to anterior wall thickness limitations. The results are interesting. Average chest wall thickness at the right side anterior second intercostal space, lateral forth and fifth mid-axillary locations were 46.4 mm, 53.8 mm and 63.7 mm, respectively. When considering the one factor of chest wall thickness as it relates to successful penetration of the plural space, the researchers concluded, the anterior location is superior. Furthermore, attempting to overcome the increased chest wall thickness at the lateral mid-axillary locations by using a longer catheter is risky, for it increases the risk of damaging surrounding vascular structures.

While this study does not address the larger issue of practitioners misplacement at the anterior location, it does illicit and attempt to answer an important question of impulsively changing training doctrine to emphasize the lateral location.

*Anterior Versus Lateral Needle Decompression of Tension Pneumothorax: Comparison by Computed Tomography Chest Wall Measurement by Sanchez, Leon, MD, MPH, et al. Academic Emergency Medicine 2011; 18:1022-1026 by the Society for Academic Emergency Medicine

SOFTT Added to TCCC Instructions

The SOF Tactical Tourniquet has always been TCCC approved, but until recently, it has been overlooked when it comes to official TCCC instructions and guides. Here is the link to the most recent Care Under Fire PowerPoint produced by the TCCC board that outline the instructions. Furthermore, the second link below has many other training aides for all phases of tactical medicine.

CUF Link

General TCCC Links

How to:One-handed Tourniquet Application

A principal learning objective taught in many tactical medical training programs is self-application of tourniquets. Although reports from current battlefields estimate the frequency of one-handed application at less 1/10 of 1% (o.oo1), it is still a valuable drill for those working alone (i.e., law enforcement officers). Unfortunately, the technique taught is often incorrect, as most disregard the fact that if one is applying a tourniquet to one’s limb, the limb is probably injured. Therefore, as the video demonstrates, one ought to train for real-world application.

Importance of Training Forward Life Saving Procedures and Future Blood Protocols

In a recent article published in the Journal of Trauma Injury, Infection, and Critical Care, the authors analyzed the effect of life-saving interventions (LSI) performed by combat medics and other forward providers. The medical practitioners in the study were arranged in an EMS style hierarchy under a medical director, with the majority of medics trained to the EMT-B level, in addition to supplemental training in TCCC-approved LSI procedures. Additionally, they analyzed outcomes with an eye toward the applicability of more advanced care in the form of Remote Damage Resuscitation protocols. As summarized below, they found that forward deployment of blood products would be beneficial if the logistical and scope-of-practice concerns could be addressed. In the limitations section of the study, they concede that certain biases might have affected the outcome. They note, for instance, “[t]he differential impact of transport time from point-of-injury to surgical facility arrival is worth considering.” Time from injury to point-of-injury treatment, time between request for evacuation to arrival of transportation, and time from extraction to the study facility all affected the outcomes, some of which were unknown in retrospect.

Although the authors did acknowledge in the conclusion that LSI need to be performed sooner, they unfortunately continued to argue that their notional blood protocol would have been beneficial. This is despite the fact that the majority of LSI were preformed by PA-level practitioners or higher, which is the major concern, because that indicates that urgent and priority patients were evacuated without LSI. It is difficult to surmise why LSI were not performed sooner, due to the nature of record keeping and retrospective studies. Perhaps tactical considerations dictated transport before treatment, or casualties deteriorated during evacuation. Nonetheless, early treatment is paramount, so training might possibly the more important to allocate resources to than blood protocols. Technology is an exceptional adjunct to the basics, but medics must have a foundation upon which to build.

Background: To analyze casualties from the Camp Eagle Study, focusing on
life-saving interventions (LSI) and potentially survivable deaths.

Methods: Retrospective cohort of battle casualties from a forward base engaged in urban combat in Central Iraq. Medical support included emergency medicine practitioners and combat medics with advanced training and protocols. LSI were defined as advanced airway, needle or tube thoracostomy, tourniquet, and hypotensive resuscitation with Hetastarch. Cases were assessed retrospectively for notional application of a Remote Damage Control Resuscitation protocol using blood products.

Results: Three hundred eighteen subjects were included. The case fatality rate was 7%. “Urgent” (55) or “priority” (88) medical evacuation was required for 45% of casualties. Sixty-one LSI were performed, in most cases by the physician or PA, with 80% on “urgent” and 9% on “priority” casualties, respectively. Among survivors requiring LSI, the percentage actually performed were airway 100%; thoracostomy 100%; tourniquet 100%; hetastarch 100%. Among nonsurvivors, these percentages were 78%, 50%, 100%, and 56%, respectively. Proximate causes of potentially survivable death were delays in airway placement and ventilation (40%), no thoracostomy (20%), and delayed evacuation
resulting in hemorrhagic shock (60%). The notional Remote Damage Control Resuscitation protocol would have been appropriate in 15% of “urgent” survivors
and in 26% of nonsurvivors.

Conclusion: LSI were required by most urgent casualties, and a lack or delay in their performance was associated with increased mortality. Forward deployment of blood components may represent the next addition to LSI if logistical and scope-of-practice issues can be overcome.

(J Trauma. 2011;71: S109–S113)