Page 143 - Journal of Special Operations Medicine - Fall 2014

Committee for Tactical Emergency Casualty Care
(C-TECC) Update: Fall 2014

David Callaway, MD; Reed Smith, MD;
Geoff Shapiro, EMT-P; Joshua Bobko, MD; Sean McKay, EMT-P

JUNE 2014 TECC GUIDELINES
COMMITTEE MEETING

The Johns Hopkins Center for Law Enforcement Medi- C-TECC recommends the employment of a tiered strat-
cine and Division of Special Operations in Baltimore egy for chest decompression that includes techniques
generously hosted the June 2014 Committee for Tacti- such as needle decompression, burping of the wound,
cal Emergency Casualty Care meeting (C-TECC). The or, rarely (and with proper protection and training),
C-TECC meeting focused on several critical issues in- finger thoracostomy. Standard emergency medical ser-
cluding guideline updates, review of C-TECC member vices (EMS) practice already accounts for most of these
involvement in recent federal efforts regarding active vi- changes, so existing protocols based on the National
olent incidents, examination of national best practices, Education Standards do not necessarily need to be up-
and new partnership agreements. dated. If an agency is considering developing a new
standard operating procedure for management of pen-
etrating chest trauma or updating equipment stocks,
Guideline Updates
vented chest seals likely offer some clinical advantage
Updated language will be added to www.c-tecc.org. without a significant difference in cost.

Vented Chest Seals Penetrating Eye Injuries
Recently, based on two laboratory animal trials (Evi- Given the infrequency of eye injuries, the availability of
dence Level C), the CoTCCC changed the recom- rapid access to emergency medicine or ophthalmology
mendations for management of open pneumothorax/ specialists, and member input on existing civilian pro-
penetrating chest trauma to emphasize the use of vented tocols, the C-TECC has simplified recommendations for
chest seals. In their study, Kotora et al. created a surgical eye injury management. During the public comment pe-
thoracostomy, sealed the hole, and then infused a com- riod, several guests questioned the utility of field visual
bination of air and blood into the chest cavity. The study acuity tests in the civilian setting. In most situations,
found that the HyFin, Sentinel, and SAM chest seals all people thought that this simply added time to the evacu-
effectively prevented development of tension physiol- ation and provided little additional clinical information.
ogy. A second laboratory animal trial by Kheirabadi et New recommendations call for simply protecting the
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al. demonstrated that violation of the chest wall created eye from external pressure and stabilizing the object (if
immediate respiratory distress (presumably be eliminat- present). As with all recommendations, the tactical and
ing the negative pressure gradient required for proper operational scenario should inform clinical decisions.
respiration). Occlusion of the hole immediately restored
normal respiratory mechanics. However, serial air in- Pediatric Populations
jections resulted in tension physiology in models with While jurisdictions across the county and internationally
nonvented chest seals. Vented chest seals prevented this are racing to improve their response to Active Violence
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outcome. Based on these two trials, the C-TECC has Incidents (AVIs), there has been a long-standing lack of
added language to include the use of vented chest seals guidance with respect to treatment of nontraditional
if available. Unlike CoTCCC, C-TECC guidelines com- populations. While AVIs should not dominate guidance
mittee did not believe that clear superiority in terms of on trauma care, increased awareness of these events
clinical outcome with vented versus nonvented chest provides an opportunity to drive a paradigm shift in the
seals with a comprehensive decompression strategy. prehospital treatment of these patients. Within the past
In the civilian setting, with relatively short transport 2 years, events involving public locations (e.g., schools,
times, the likelihood of developing a fatal tension pneu- churches, and theaters) have attracted the attention of
mothorax remains rare, even in cases of penetrating the national media. Most, if not all, have involved pe-
chest trauma. If an agency is using occlusive chest seals, diatric casualties. In 2013, the C-TECC formally stood

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