Page 89 - Journal of Special Operations Medicine - Fall 2017

Chest Seal Placement for Penetrating Chest Wounds
by Prehospital Ground Forces in Afghanistan

Steven G. Schauer, DO, MS *; Michael D. April, MD, PhD ; Jason F. Naylor, PA-C ;
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Erica M. Simon, DO, MHA ; Andrew D. Fisher, PA-C ; Cord W. Cunningham, MD, MPH ;
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Daniel Morissette, NREMT-P, ATP ; Jessie Renee D. Fernandez, BS ; Kathy L. Ryan, PhD 9
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ABSTRACT
Background: Thoracic trauma represents 5% of all battlefield individuals who succumbed to thoracic injury, an estimated 3%
injuries. Communicating pneumothoraces resulting in tension to 4% perished secondary to a tension pneumothorax. Because
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physiology remain an important etiology of prehospital mor- an open pneumothorax predisposes to the development of tension
tality. In addressing penetrating chest trauma, current Tactical physiology, rapid treatment of this injury is imperative, as de-
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Combat Casualty Care (TCCC) guidelines advocate the immedi- tailed in the Tactical Combat Casualty Care (TCCC) guidelines. 8
ate placement of a vented chest seal device. Although the Com-
mittee on TCCC (CoTCCC) has approved numerous chest seal As of 2013, TCCC guidelines recommend the immediate appli-
devices for battlefield use, few data exist regarding their use in a cation of a vented chest seal to all open or sucking chest wounds.
combat zone setting. Objective: To evaluate adherence to TCCC Before 2013, the guidelines recommended placement of a chest
guidelines for chest seal placement among personnel deployed seal for open or sucking wounds without specifying a require-
to Afghanistan. Methods: We obtained data from the Prehos- ment for vented chest seal use. Should a vented chest seal not be
pital Trauma Registry (PHTR). Joint Trauma System personnel available, the current guidelines advise use of a nonvented chest
linked patients to the Department of Defense Trauma Registry, seal, as previously recommended. The recommendation to rely
when available, for outcome data upon reaching a fixed facility. preferentially on vented chest seals arose from animal studies
Results: In the PHTR, we identified 62 patients with documented demonstrating the development of tension physiology after the
gunshot wound (GSW) or puncture wound trauma to the chest. application of nonvented chest seals to open pneumothoraces
The majority (74.2%; n = 46) of these were due to GSW, with the with intrathoracic air leak. In casualties exhibiting signs or
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remainder either explosive-based puncture wounds (22.6%; n = symptoms of tension pneumothorax after chest seal application
14) or a combination of GSW and explosive (3.2%; n = 2). Of (i.e., respiratory distress, hypoxia, or hypotension), providers
the 62 casualties with documented GSW or puncture wounds, should initiate treatment by either burping of the chest seal, re-
46 (74.2%) underwent chest seal placement. Higher proportions moving the dressing, or performing needle decompression. 9
of patients with medical officers in their chain of care under-
went chest seal placement than those that did not (63.0% ver- The primary goal of this investigation is to describe adherence
sus 37.0%). The majority of chest seals placed were not vented. to chest seal placement in accordance with TCCC guidelines.
Conclusion: Of patients with a GSW or puncture wound to the
chest, 74.2% underwent chest seal placement. Most of the chest Methods
seals placed were not vented in accordance with guidelines, de-
spite the guideline update midway through the study period. Patients were casualties in Afghanistan during Operation En-
These data suggest the need to improve predeployment training during Freedom from January 2013 to September 2014. We
on TCCC guidelines and matching of the Army logistical supply obtained prehospital data from the Prehospital Trauma Reg-
chain to the devices recommended by the CoTCCC. istry (PHTR), which is a module of the Department of De-
fense Trauma Registry (DoDTR); the Joint Trauma System
Keywords: chest; wound; seal; prehospital; military; combat (JTS) compiles and maintains both databases at the U.S. Army
Institute of Surgical Research (USAISR). JTS personnel then
linked patients from the PHTR to the DoDTR to obtain fixed-
facility treatment and outcome data when available. Only de-
Introduction
identified data were available to the research team; therefore,
Explosives and gunshot wounds (GSW) are common mechanisms the USAISR regulatory office determined that the study did
of thoracic injury in the battlefields of Iraq and Afghanistan, with not require institutional review board review.
thoracic trauma representing 5% of all battlefield injuries.
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Widespread use of body armor has reduced the incidence of We queried the PHTR database for all patients with a docu-
thoracic trauma, but mortality rates among those with thoracic mented GSW or puncture wound to the chest. We excluded
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injuries remain relatively unchanged since Vietnam. Among injuries documented as lacerations or peppering.
*Correspondence to steven.g.schauer.mil@mail.mil
1 MAJ Schauer is at the U.S. Army Institute of Surgical Research and the San Antonio Military Medical Center, JBSA Fort Sam Houston, TX.
2 MAJ April is at the San Antonio Military Medical Center, JBSA Fort Sam Houston, TX. MAJ Naylor is with the 28th Combat Support Hos-
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pital, Fort Bragg, NC. Capt Simon is at the San Antonio Military Medical Center, JBSA Fort Sam Houston, TX. MAJ Fisher is at Texas A&M
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University, College of Medicine, Temple, TX, and is with the 7249th Medical Support Unit, Joint Forces Reserve Center Ellington Field, Houston,
TX. LTC Cunningham is with the Carl R. Darnall Army Medical Center and is with the 1st Cavalry Division, Fort Hood, TX. SSG Morissette
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is with Special Operations Command South, Homestead Air Reserve Base, FL. Ms Fernandez is at the U.S. Army Institute of Surgical Research,
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JBSA Fort Sam Houston, TX. Dr Ryan is at the U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX.
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