Page 21 - JSOM Summer 2018

Management of Suspected Tension Pneumothorax
in Tactical Combat Casualty Care

TCCC Guidelines Change 17-02

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Frank Butler, MD ; John Holcomb, MD ; Stacy Shackelford, MD ; Harold Montgomery, ATP ;
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Shawn Anderson, NREMT-P ; Jeff Cain, MD ; Howard Champion, MD ; Cord Cunningham, MD ;
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Warren Dorlac, MD ; Brendon Drew, DO ; Kurt Edwards, MD ; John Gandy, MD ;
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Elon Glassberg, MD ; Jennifer Gurney, MD ; Theodore Harcke, MD, PhD ; Don Jenkins, MD ;
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Jay Johannigman, MD ; Bijan Kheirabadi, PhD ; Russ Kotwal, MD ; Lanny Littlejohn, MD ;
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Matthew Martin, MD ; Edward Mazuchowski, MD, PhD ; Edward J. Otten, MD ;
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Travis Polk, MD ; Peter Rhee, MD ; Jason Seery, MD ; Zsolt Stockinger, MD ;
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Jeremy Torrisi, ATP ; Avi Yitzak, MD ; Ken Zafren, MD ; Scott Zietlow, MD 31
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ABSTRACT
This change to the Tactical Combat Casualty Care (TCCC) in hemoglobin oxygen saturation; and/or an improvement in
Guidelines that updates the recommendations for manage- signs of shock that may be present. (7) Recommends that only
ment of suspected tension pneumothorax for combat casual- two needle decompressions be attempted before continuing on
ties in the prehospital setting does the following things: (1) to the “Circulation” portion of the TCCC Guidelines. After
Continues the aggressive approach to suspecting and treating two NDCs have been performed, the combat medical provider
tension pneumothorax based on mechanism of injury and re- should proceed to the fourth element in the “MARCH” algo-
spiratory distress that TCCC has advocated for in the past, as rithm and evaluate/treat the casualty for shock as outlined in
opposed to waiting until shock develops as a result of the ten- the Circulation section of the TCCC Guidelines. Eastridge’s
sion pneumothorax before treating. The new wording does, landmark 2012 report documented that noncompressible
however, emphasize that shock and cardiac arrest may ensue hemorrhage caused many more combat fatalities than ten-
if the tension pneumothorax is not treated promptly. (2) Adds sion pneumothorax. Since the manifestations of hemorrhagic
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additional emphasis to the importance of the current TCCC shock and shock from tension pneumothorax may be similar,
recommendation to perform needle decompression (NDC) on the TCCC Guidelines now recommend proceeding to treat-
both sides of the chest on a combat casualty with torso trauma ment for hemorrhagic shock (when present) after two NDCs
who suffers a traumatic cardiac arrest before reaching a med- have been performed. (8) Adds a paragraph to the end of the
ical treatment facility. (3) Adds a 10-gauge, 3.25-in needle/ Circulation section of the TCCC Guidelines that calls for con-
catheter unit as an alternative to the previously recommended sideration of untreated tension pneumothorax as a potential
14-gauge, 3.25-in needle/catheter unit as recommended de- cause for shock that has not responded to fluid resuscitation.
vices for needle decompression. (4) Designates the location at This is an important aspect of treating shock in combat casu-
which NDC should be performed as either the lateral site (fifth alties that was not presently addressed in the TCCC Guide-
intercostal space [ICS] at the anterior axillary line [AAL]) or lines. (9) Adds finger thoracostomy (simple thoracostomy) and
the anterior site (second ICS at the midclavicular line [MCL]). chest tubes as additional treatment options to treat suspected
For the reasons enumerated in the body of the change report, tension pneumothorax when further treatment is deemed nec-
participants on the 14 December 2017 TCCC Working Group essary after two unsuccessful NDC attempts—if the combat
teleconference favored including both potential sites for NDC medical provider has the skills, experience, and authorizations
without specifying a preferred site. (5) Adds two key elements to perform these advanced interventions and the casualty is in
to the description of the NDC procedure: insert the needle/ shock. These two more invasive procedures are recommended
catheter unit at a perpendicular angle to the chest wall all the only when the casualty is in refractory shock, not as the initial
way to the hub, then hold the needle/catheter unit in place for treatment.
5 to 10 seconds before removing the needle in order to allow
for full decompression of the pleural space to occur. (6) Defines Keywords: guidelines; tension pneumothorax; Tactical Com-
what constitutes a successful NDC, using specific metrics such bat Casualty Care
as: an observed hiss of air escaping from the chest during the
NDC procedure; a decrease in respiratory distress; an increase
1–31 Please see page 35.
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