Page 140 - JSOM Fall 2018

g. Always remember that the casualty’s airway status may *The needle/catheter unit should be inserted at an angle per­
change over time and requires frequent reassessment. pendicular to the chest wall and just over the top of the lower
Notes: rib at the insertion site. Insert the needle/catheter unit all the
*The i­gel is the preferred extraglottic airway because its gel­ way to the hub and hold it in place for 5­10 seconds to allow
filled cuff makes it simpler to use and avoids the need for cuff decompression to occur.
inflation and monitoring. If an extraglottic airway with an air­
filled cuff is used, the cuff pressure must be monitored to avoid *After the NDC has been performed, remove the needle and
overpressurization, especially during TACEVAC on an aircraft leave the catheter in place.
with the accompanying pressure changes. 3. The NDC should be considered successful if:
– Respiratory distress improves, or
*Extraglottic airways will not be tolerated by a casualty who – There is an obvious hissing sound as air escapes from
is not deeply unconscious. If an unconscious casualty without the chest when NDC is performed (this may be difficult
direct airway trauma needs an airway intervention, but does to appreciate in high­noise environments), or
not tolerate an extraglottic airway, consider the use of a naso­ – Hemoglobin oxygen saturation increases to 90% or
pharyngeal airway. greater (note that this may take several minutes and may
not happen at altitude), or
*For casualties with trauma to the face and mouth, or facial
burns with suspected inhalation injury, nasopharyngeal air­ – A casualty with no vital signs has return of conscious­
ways and extraglottic airways may not suffice and a surgical ness and/or radial pulse.
cricothyroidotomy may be required. 4. If the initial NDC fails to improve the casualty’s signs/
symptoms from the suspected tension pneumothorax:
*Surgical cricothyroidotomies should not be performed on un­ – Perform a second NDC on the same side of the chest at
conscious casualties who have no direct airway trauma unless whichever of the two recommended sites was not previ­
use of a nasopharyngeal airway and/or an extraglottic airway ously used. Use a new needle/catheter unit for the sec­
have been unsuccessful in opening the airway. ond attempt.
5. Respiration/Breathing – Consider, based on the mechanism of injury and physi­
a. Assess for tension pneumothorax and treat as necessary. cal findings, whether decompression of the opposite side
1. Suspect a tension pneumothorax and treat when of the chest may be needed.
a casualty has significant torso trauma or primary 5. If the initial NDC was successful, but symptoms later recur:
blast injury and one or more of the following: – Perform another NDC at the same site that was used
– Severe or progressive respiratory distress previously. Use a new needle/catheter unit for the repeat
– Severe or progressive tachypnea NDC.
– Absent or markedly decreased breath sounds on – Continue to reassess!
one side of the chest 6. If the second NDC is also not successful:
– Hemoglobin oxygen saturation < 90% on pulse – Continue on to the Circulation section of the TCCC
oximetry Guidelines.
– Shock b. All open and/or sucking chest wounds should be treated
– Traumatic cardiac arrest without obviously fatal by immediately applying a vented chest seal to cover the
wounds defect. If a vented chest seal is not available, use a non­
Note: vented chest seal. Monitor the casualty for the potential
*If not treated promptly, tension pneumothorax may prog­ development of a subsequent tension pneumothorax. If
ress from respiratory distress to shock and traumatic cardiac the casualty develops increasing hypoxia, respiratory
arrest. distress, or hypotension and a tension pneumothorax is
2. Initial treatment of suspected tension pneumothorax: suspected, treat by burping or removing the dressing or
– If the casualty has a chest seal in place, burp or by needle decompression.
remove the chest seal. c. Initiate pulse oximetry. All individuals with moderate/
– Establish pulse oximetry monitoring. severe TBI should be monitored with pulse oximetry.
– Place the casualty in the supine or recovery po­ Readings may be misleading in the settings of shock or
sition unless he or she is conscious and needs to marked hypothermia.
sit up to help keep the airway clear as a result of d. Casualties with moderate/severe TBI should be given
maxillofacial trauma. supplemental oxygen when available to maintain an ox­
– Decompress the chest on the side of the injury ygen saturation > 90%.
with a 14­gauge or a 10­gauge, 3.25­inch needle/ 6. Circulation
catheter unit. a. Bleeding
– If a casualty has significant torso trauma or pri­ • A pelvic binder sh
mary blast injury and is in traumatic cardiac arrest • Could be applied for cases of suspected pelvic fracture:
(no pulse, no respirations, no response to painful – Severe blunt force or blast injury with one or
stimuli, no other signs of life), decompress both more of the following indications:
sides of the chest before discontinuing treatment. o Pelvic pain
Notes: o Any major lower limb amputation or near
*Either the 5th intercostal space (ICS) in the anterior axillary amputation
line (AAL) or the 2nd ICS in the mid­clavicular line (MCL) o Physical exam findings suggestive of a pelvic
may be used for needle decompression (NDC.) If the anterior fracture
(MCL) site is used, do not insert the needle medial to the nip­ o Unconsciousness
ple line. o Shock

138 | JSOM Volume 18, Edition 3 / Fall 2018