Page 88 - Journal of Special Operations Medicine - Spring 2016

Casualty care supply vendors Combat Medical Sys-
Needle Decompression tems (http://www.combatmedicalsystems.com), H&H
Medical (http://buyhandh.com), and North American
by Nicholas M. Studer, MD, EMT-P; Gregory T. Horn, MD Rescue Products (http://www.narescue.com) produce
near-identical ruggedized packaging that is similar to a
10
cigar tube. They omit the flash cap and have a single-
hile the incidence of tension pneumothorax component protective sheath, thus eliminating the prob-
in American war-wounded Servicemembers
Whas decreased since the introduction of body lems with using the BD device (Figure 1). For this reason,
they are specified for most field medical equipment sets.
armor, it remains one of the “big three” causes of pre- However, the BD version is often purchased by medi-
1–3
ventable combat death. Needle thoracostomy remains cal units because it can be inexpensively ordered from
the treatment of choice for decompressing trapped air standard medical-surgical supply vendors and, thus, is
from bronchopleural fistulas, “sucking chest wounds,” frequently encountered by personnel who may not have
or some combination thereof. While needle decompres- previously trained with it.
4
sion (ND) superficially appears to be a technically sim-
ple procedure, it is often performed by providers with Figure 1 Currently available devices.
minimal training; almost all deployed personnel are re-
sponsible for this skill because it is taught during Com-
bat Lifesaver courses for lay field-care personnel. The
3,5
authors have identified several common pitfalls during
cadaver- and animal-based training of field medical
personnel that have not been previously emphasized in
common training guidance.

There are several brands of catheter-over-needle devices
commonly sold for battlefield ND. The original was the
Becton Dickinson 14-gauge × 3.25-inch Angiocatheter
for Special Placement (BD; http://www.bd.com), which
is still packaged in civilian medical format with a peel-
6
open sleeve. Users must be aware that the plastic sheath
on the device consists of two separate pieces, with a slip-
on extension of plastic. The authors have observed nov-
ice users under stress attempting to use the device after Moreover, with both brands, we have observed users
pulling off the extension without removing the main grasp the orange-colored plastic catheter while at-
portion of the sheath, resulting in premature stoppage at tempting to insert the device into the chest. With this
approximately a 1-inch depth into the chest, an insuffi- technique, the needle within the catheter is only held
cient depth to be effective. Instructors should encour- by friction, and the cutting tip is quickly pushed inside
7,8
age trainees to grasp the sheath at the proximal end, the plastic catheter. Little force is applied to the rigid
not the tip, when removing. Additionally, users must be needle, and the catheter typically kinks or “accordi-
instructed to remove the rear flashback chamber cap to ons” at the distal end—a known cause of needle de-
allow air to exit the needle and potentially allow for compression failures. In effect, the user has changed
11
hearing or feeling air release upon entering the pleural a sharp device into a blunt trocar that is difficult to
cavity. The current Tactical Combat Casualty Care skill force through the thick muscles of the chest. This phe-
sheet does include the following instructions: “Remove nomenon, with resultant failure to penetrate the chest,
the plastic cap from the 3.25-inch, 14-gauge needle. is visible in recent nationally televised footage of ca-
Also remove the cover to the needle’s flash chamber.” sualty evacuations in Afghanistan and probably oc-
9
However, it is not at all clear to novice users that, due curs more frequently with an anterior approach due
to the BD product design, there are effectively two plas- to glancing rib impacts and the depth of penetration
tic sheaths and a back cap, in addition to the casing in required at this angle. Providers must be reminded
12
which the device is shipped. that the needle and its cutting tip are the central focus

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