Page 24 - JSOM Summer 2018

– “In a casualty with progressive respiratory distress and – Tracheal deviation
known or suspected torso trauma, consider a tension pneu- – Jugular venous distention
mothorax and decompress the chest on the side of the in- – Shift of the mediastinal contents away from the side of the
jury with a 14-gauge, 3.25-in needle/catheter unit inserted tension pneumothorax
in the second intercostal space at the midclavicular line. – Tachycardia
Ensure that the needle entry into the chest is not medial to – Shock
the nipple line and is not directed toward the heart. An ac- – Cardiac arrest
ceptable alternate site is the fourth or fifth intercostal space
at the anterior axillary line (AAL).” In reviewing these potential signs and symptoms, the CoTCCC
– Additionally, NDC of both sides of the chest is recom- sought to identify those that would be of greatest use to a com-
mended for any casualty who has a prehospital traumatic bat medical provider in identifying a possible tension pneu-
cardiac arrest. mothorax in the prehospital combat setting and indicating the
– In the tactical evacuation (TACEVAC) phase of care, need for NDC.
tube thoracostomy is recommended if that procedure is
within the skill set of the individual providing care during In order to make tension pneumothorax a significant consid-
evacuation. eration in evaluating a combat casualty, there must be an in-
jury of sufficient severity and in the appropriate location to
This review considers the recommendations for treatment of a produce the one-way air leak that results in the accumulation
casualty with suspected pneumothorax in TCCC by discussing of air under pressure in the pleural space. In a combat setting,
the following questions: that injury may be penetrating (GSW or fragment wound),
– When should a tension pneumothorax be suspected in a blunt trauma (as with a combat-related motor vehicle crash
combat casualty? or a fall), or, less commonly, pulmonary overpressure injury
– What should be the initial treatment of a suspected tension resulting from exposure to a blast wave.
pneumothorax?
– How should the casualty be positioned for NDC? Prehospital care guidelines in some civilian trauma systems are
– What device should be used for needle decompression? well-aligned with the TCCC approach of treating suspected
– What site should be used for NDC? tension pneumothorax on the basis of respiratory distress
– What is the best needle decompression technique? with or without accompanying hypotension if there is clini-
– What findings indicate that NDC has been successful? cal evidence of blunt or penetrating chest trauma. 9,55–57 In one
– What should be done if the initial NDC is not successful? emergency medical services (EMS) system in Australia, the use
– What should be done if the initial NDC is successful but of a more aggressive approach to suspected tension pneumo-
signs/symptoms subsequently recur? thorax was documented to cause a decrease in unrecognized
– What should be done if the second NDC is also not episodes of this disorder. Respiratory distress/tachypnea and
56
successful? decreased or absent breath sounds on the affected side are a
– What site should be use for NDC? very common finding in tension pneumothorax. 6,28,31 Other
– What is the prehospital treatment of refractory shock? signs such as jugular vein distention and tracheal shift were
less useful in the prehospital environment. 6,55
Discussion
Other authors, however, place relatively more emphasis on the
When should a tension pneumothorax be suspected in a com- presence of shock as an indication for performing NDC for
bat casualty? suspected tension pneumothorax in the presence of thoracic
TCCC has historically advocated for an aggressive approach trauma. 6,53,54 This presents the question of whether or not one
to treating suspected tension pneumothorax, with the origi- should wait for shock to develop in a casualty with thoracic
nal TCCC report stating: “Progressive, severe respiratory dis- trauma and respiratory distress before undertaking NDC,
tress on the battlefield resulting from unilateral penetrating or since NDC is not a completely benign procedure.
blunt chest trauma should be considered to represent a tension
pneumothorax and that hemithorax decompressed with a 14 The Mayo Clinic study by Aho and colleagues noted respira-
gauge catheter. The diagnosis in this setting should not rely on tory improvement in 24 patients and hemodynamic improve-
such typical clinical signs as breath sounds, tracheal shift, and ment in only 4 patients after treatment for suspected tension
hyperresonance on percussion because these signs may not al- pneumothorax, suggesting that prehospital personnel treated
ways be present and, even if they are, they may be exceedingly suspected ten sion pneumothorax largely on the basis of respi-
difficult to appreciate on the battlefield . . . (NDC) is techni- ratory symptoms before the tension pneumothorax progressed
cally easy to perform, and may be lifesaving if the patient does and caused hemodynamic compromise and shock. The study
9
in fact have a tension pneumothorax.” 45 by Leigh-Smith states that respiratory distress is a universal
finding in tension pneumothorax, while hypotension is present
There are many signs and symptoms reported in the litera- in only 25% of cases. Roberts’ review of case reports of ten-
31
ture as manifestations of a developing tension pneumotho- sion pneumothorax noted that, in 86 spontaneously breathing
rax. 9,28,31,53–55 A partial list includes: patients, 45 had chest pain, 33 had dyspnea, 27 had shortness
– Dyspnea—the subjective feeling of respiratory distress of breath, 36 had respiratory distress, and 40 had tachypnea,
– Increased depth and frequency of respirations while only 16 had hypotension. 28
– Decreased hemoglobin oxygen saturation
– Decreased or absent breath sounds Leigh-Smith and colleagues noted that, in animal models of
– Hyperresonance to percussion tension pneumothorax: “The dominant physiological feature
– Subcutaneous emphysema during decompensation was progressive respiratory failure

22 | JSOM Volume 18, Edition 2/Summer 2018