Page 31 - JSOM Summer 2018

patent. If a needle thoracostomy becomes obstructed, it is sim- followed by either simple (finger) thoracostomy or chest tube
pler to put in a second one rather than attempt a chest tube in placement, but only if shocks persists after two attempts at
the field. The 2nd needle thoracostomy should be just as effec- needle decompression and after having accomplished the other
tive as the first one. Continuous monitoring and reassessment of circulation measures listed above. In cases of pneumothorax
patients is necessary whether a needle or chest tube is in place.” 85 or hemothorax, a simple (finger) thoracostomy will defini-
tively ensure that the pleural cavity has been entered and de-
compressed, while tube thoracostomy will drain the chest and
Recommendation:
allow the lung to re-expand. Only those combat medical pro-
If the initial NDC was successful, but symptoms later recur: viders who have the appropriate skills, equipment, and autho-
– Perform another NDC at the same site that was used previ- rization should perform these invasive procedures.
ously. Use a new needle/catheter unit for the repeat NDC.
– Continue to re-assess! A description of finger thoracostomy (FT) was provided by
High: “FT is performed the same way (as tube thoracostomy),
What should be done if the second NDC is also not successful? but a tube is not introduced immediately into the pleural cav-
If two needle decompressions have been attempted and there ity. FT serves as a quick and definitive way to address or rule
has been no clinical improvement, the casualty’s signs and out tension pneumothorax.” No studies were identified,
53
symptoms may be caused by hemorrhagic shock or other con- however, that document that finger thoracostomies will reli-
ditions. The treating combat medical provider should there- ably remain patent and continue to prevent tension pneumo-
fore turn his or her attention to the next step in the sequence thorax in the presence of an ongoing air leak from the lung
of care in the TCCC Guidelines—Circulation. injury without chest tube insertion.

Chest trauma that causes clinically significant pneumothorax
Recommendation:
or hemothorax will be treated with immediate tube thoracos-
If the second NDC is also not successful: tomy at the casualty’s first medical treatment facility, but insert-
– Continue on to the Circulation section of the TCCC ing chest tubes in the prehospital combat setting has not been
Guidelines. well-documented to improve outcomes. A 1985 Israeli study
reported that only 8 of 16 prehospital chest tubes were inserted
What is the prehospital treatment of refractory shock? correctly and for the appropriate indications by physicians.
88
Although untreated tension pneumothorax can potentially re- A more recent study from the Israeli Defense Force noted that
sult in shock and death, a far more common cause of prevent- 35 prehospital chest tubes had been placed after failed NDC,
able death on the battlefield is shock that results from ongoing but the difference in outcomes associated with use of this more
noncompressible hemorrhage. Shock from massive hemorrhage invasive intervention were not well described. There are reports
6
and shock from tension pneumothorax may be difficult to dif- from the civilian sector that indicate that simple or tube tho-
ferentiate in the prehospital setting, since there may be con- racostomy can be safely and effectively accomplished by pre-
siderable overlap in the physical findings. Since hemorrhagic hospital personnel and should be considered when NDC has
shock is a far more common cause of preventable death in com- failed. 31,34,53,57,68,89,90 The importance of experience in perform-
bat casualties than shock from tension pneumothorax, and ing tube thoracostomy was highlighted by a 2017 study which
1
since NDC will treat only the latter condition, it is important noted that the complication rate for chest tube insertion was sig-
to undertake hemorrhage control and resuscitation measures nificantly greater (17%) when the procedure was performed by
before returning to the possibility of a tension pneumothorax. interns compared with 7% when the procedure was performed
by residents. Another study found that clinical improvement
91
The combat medical provider should, therefore, proceed after tube thoracostomy was 61% compared with an improve-
through the circulation section of the TCCC Guidelines and: ment rate after NDC of 54%. The lack of a large increase in the
– Ensure that all external hemorrhage is controlled 3 clinical improvement rate in this study is an important point to
– Apply a pelvic binder if indicated 86 bear in mind when considering more invasive interventions.
92
– Assess for shock The authors of that study concluded: “From these data, we
– Start an IV or IO infusion if needed conclude that (needle decompression) is a relatively rapid inter-
– Administer TXA if hemorrhagic shock is present or likely 87 vention in the treatment of suspected (tension pneumothorax)
– Perform fluid resuscitation with blood products if possible 25 in the prehospital setting; however, (tube thoracostomy) is an
effective adjunct for definitive care without increasing morbid-
After all of the above interventions have been performed as in- ity or mortality. A better understanding of the physiology of
dicated, if the shock state persists, the combat medical provider intrapleural air masses is needed to determine the most effective
should consider untreated tension pneumothorax as a possible decompression requirements prior to aeromedical transport.” 92
cause of refractory shock. Findings of thoracic trauma, per-
sistent respiratory distress, absent breath sounds on one side Consideration should also be given to decompressing the con-
of the chest, and hemoglobin oxygen saturation less than 90% tralateral side of the chest if the injury pattern suggests that
would lend support to this diagnosis. In a casualty who has that is appropriate. Other interventions that may alleviate
had at least two failed NDCs and who is suffering from refrac- shortness of breath include ketamine administration for pain
tory shock, more definitive measures need to be considered. 82 control and supplemental oxygen.
3
Suspected tension pneumothorax should be treated in the Recommendation:
prehospital setting with the least invasive intervention that
will successfully resolve the casualty’s shock and/or respira- If a casualty in shock is not responding to fluid resuscitation,
tory distress. This translates to needle decompression first, consider untreated tension pneumothorax as a possible cause

TCCC Guidelines Change 17-02 | 29