Page 32 - JSOM Summer 2018

of refractory shock. Thoracic trauma, persistent respiratory of both the anterior and the lateral sites using the highest fidel-
distress, absent breath sounds, and hemoglobin oxygen satu- ity simulators available—fellow TCCC students. This training
ration < 90% support this diagnosis. Treat as indicated with methodology mirrors that now used in TCCC courses to help
repeated NDC or finger thoracostomy/chest tube insertion at students accurately identify the correct site for surgical crico-
the fifth ICS in the AAL, according to the skills, experience, thyroidotomy. Demonstration of the procedure can then be
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and authorizations of the treating combat medical provider. performed on a manikin or a partial task trainer. The use of
Note that if finger thoracostomy is used, it may not remain a cadaver-based training program to train this procedure has
patent and finger decompression through the incision may been found to result in improved performance over slide-based
have to be repeated. Consider decompressing the opposite side instruction alone. 95
of the chest if indicated based on the mechanism of injury and
physical findings.
Proposed Change
Levels of Evidence for the Above Recommendations Current Wording in the TCCC Guidelines
The levels of evidence used by the American College of Car-
diology and the American Heart Association were outlined by Tactical Field Care
Tricoci in 2009: 5. Respiration/Breathing
– Level A: Evidence from multiple randomized trials or a. In a casualty with progressive respiratory distress and
meta-analyses. known or suspected torso trauma, consider a tension
– Level B: Evidence from a single randomized trial or non- pneumothorax and decompress the chest on the side
randomized studies. of the injury with a 14-gauge, 3.25-inch needle/cathe-
– Level C: Expert opinion, case studies, or standards of care. 93 ter unit inserted in the second intercostal space at the
midclavicular line. Ensure that the needle entry into the
Using the taxonomy above, the levels of evidence for the rec- chest is not medial to the nipple line and is not directed
ommendations in this change are shown below. towards the heart. An acceptable alternate site is the
fourth or fifth intercostal space at the anterior axillary
When should a tension pneumothorax be suspected? line (AAL).
Level C
Tactical Evacuation Care
How should the casualty be positioned for NDC? 4. Respiration/Breathing
Level C a. In a casualty with progressive respiratory distress and
known or suspected torso trauma, consider a tension
What device should be used for needle decompression? pneumothorax and decompress the chest on the side of
Level B the injury with a 14-gauge, 3.25 inch needle/catheter
unit inserted in the second intercostal space at the mid-
What site should be used for needle decompression? clavicular line. Ensure that the needle entry into the chest
Level C is not medial to the nipple line and is not directed to-
wards the heart. An acceptable alternate site is the 4th or
What technique should be used for needle decompression? 5th intercostal space at the anterior axillary line (AAL).
Level C b. Consider chest tube insertion if no improvement and/or
long transport is anticipated.
What constitutes success in the initial treatment of tension
pneumothorax? Proposed New Wording in the TCCC Guidelines
Level C
*New text in red
What should be done if the Initial needle decompression is not
successful? Tactical Field Care and Tactical Evacuation Care Respiration/
Level C Breathing
a. Assess for tension pneumothorax and treat as necessary
What should be done if the initial needle decompression is suc-
cessful but signs/symptoms subsequently recur? 1. Suspect a tension pneumothorax and treat when a casu-
Level C alty has significant torso trauma or primary blast injury
and one or more of the following:
What should be done if the second NDC is also not successful? – Severe or progressive respiratory distress
Level C – Severe or progressive tachypnea
– Absent or markedly decreased breath sounds on one
What should be the management for refractory shock due to side of the chest
tension pneumothorax? – Hemoglobin oxygen saturation < 90% on pulse
Level C oximetry
– Shock
Training for Needle Decompression – Traumatic cardiac arrest without obviously fatal
Multiple reports have documented that NDC is often per- wounds
formed at incorrect locations, especially medial to the desired *Note: If not treated promptly, tension pneumothorax may
anterior (second ICS at the MCL) site. 2,18,21 Training for needle progress from respiratory distress to shock and traumatic car-
decompression in TCCC courses should include identification diac arrest.

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