Page 25 - JSOM Summer 2022

casualty evacuation at sea might be delayed for many hours, profile (personal communication – Captain Chris (RIF) Miller,
and plasma remains in the intravascular space far longer than USMC, 22 Dec 2021).
crystalloid solutions, which might result in both a prolonged Simple (finger) thoracostomy (ST) is a more reliable method of
resuscitation effect and decreased edema fluid in the lungs, ab- chest decompression that has been shown to allow safe rotary
domen, and other body compartments.
wing evacuation in most patients. Massurutti et al reported 55
Dried plasma can be stored at ambient temperatures on ships consecutive patients treated with simple thoracostomy at the
without requiring a cold storage capability. The use of dried point of injury who were then safely evacuated by helicopter.
plasma for resuscitating casualties with burns could potentially There were no major complications or recurrent pneumotho-
be one of the more important tenets of Prolonged Casualty races during flight noted in this case series. Despite the in-
86
Care, especially in the shipboard environment, where burn in- creased reliability of ST over NDC, occlusion of the ST may
juries and prolonged delays to evacuation are both common. occur, and careful monitoring of patients during the air evacu-
Evaluation of the use of plasma as a burn resuscitation fluid ation is still a requirement after ST. If a chest tube is inserted
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should be a high-priority research item for shipboard combat in the prehospital setting, a field-expedient one-way valve can
casualty care and might offer therapeutic benefits for all burn be fashioned by simply cutting the tip off of a medical exam-
casualties. As noted by Carlotto and Callum: “Furthermore, ination glove finger and taping it in place.
lyophilized plasma has a unique potential role in military ap-
plications or for burn mass casualty scenarios . . . Modern COL Jennifer Gurney, the Chair of the Defense Committee on
and safer versions of human plasma now exist and need to be Trauma, offers this perspective.
re-evaluated in acute burn resuscitation.” 79 “A finger thoracostomy is unlikely enough for trans-
port; but, it’s multifactorial. It would depend on the
Although plasma for burns is not currently in the TCCC Guide- size of the chest wall (would the soft tissues collapse
lines, there is frozen plasma on the LHA that could be thawed and the track not stay open) and how large the air leak
and transported to the casualty ship by the EM physician and was. If there was no additional air leak, then a finger
administered to the burn casualties at his or her direction.
thoracostomy would suffice if most of the extrapleural
The DDG AMAL states that there are 12L of lactated Ringer’s air was evacuated; however, if there was a continued
solution on board. If the surgeon or the emergency medicine air leak, then the pneumothorax and potentially the
physician directing treatment elects not to use plasma, trans- tension physiology would recur. As long as the trans-
porting extra lactated Ringer’s to the casualty ship on the first port medic is comfortable venting the chest by open-
helicopter to land would provide extra fluid for the burn pa- ing the track and letting the air out, or by placing a
tients in the case of delayed evacuation. chest tube with a one-way valve. But, in a patient with
a pneumothorax and a continued air leak from injured
Treatment of Tension Pneumothorax Prior to lung, a finger thoracostomy is just a temporizing mea-
Rotary Wing TACEVAC sure.” (personal communication – COL Jennifer Gurney,
Casualty 6 suffered a tension pneumothorax from his pulmo- 2021)
nary barotrauma. The tension pneumothorax may be treated
in the prehospital setting with either needle decompression If a chest tube is not placed while on board the casualty ship,
or simple (finger) thoracostomy, 38,80 but consideration must that will need to be done either on the LHA or upon arrival
also be given to preventing a recurrence of tension physiology, at the hyperbaric treatment facility. A pneumothorax that has
both during the evacuation flight to the LHA and during sub- not been definitively treated is considered to be an absolute
sequent hyperbaric treatment for his CAGE. contraindication to hyperbaric oxygen therapy.

Several published recommendations for patients who have TCCC Equipment
been treated for pneumothorax in the hospital setting call for The medical equipment for a DDG is specified in the ship’s
a waiting period of 2–3 weeks after the pneumothorax has AMAL, however the embarked IDC, with the approval of
resolved prior to commercial air travel, 81–83 but some thoracic his or her Medical Director, may procure additional items as
surgeons recommend waiting periods of as long as 6 weeks needed.
prior to flight. 84
As noted previously, the DDG’s AMAL includes one “H” cyl-
The above recommendations, however, do not address the inder of oxygen and four “D” cylinders, although shipboard
scenario of a trauma patient who has a suspected pneumo- medical personnel report that the ships typically carry more
thorax and must be transported by AIREVAC to a definitive oxygen than that — six or eight “H” cylinders of oxygen and
treatment facility. A case series published in 2014 reported 66 approximately 16 “D” cylinders. An “H” cylinder contains
patients with confirmed traumatic pneumothoraces who were (244 cubic feet/6900L of oxygen and a “D” cylinder has 12
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transported to a Level 1 Trauma Center by helicopter with an cubic feet/340L of oxygen. A full 6900L H cylinder will sup-
89
average altitude gain of 1890 feet. No patients had prehospital ply 15L per minute of oxygen for 460 minutes (7+ hours) or
chest tubes inserted. All patients were treated with supplemen- 1380 minutes (23 hours) at 5L/min. A full (340L) D cylin-
tal oxygen and 14 of the 66 patients (21%) also had positive der would last for 22 minutes at 15L/min or 68 minutes at
pressure ventilation. Eleven of the 66 (17%) had NDC per- 5L/min. Thus, a casualty being transported who needs an oxy-
formed before flight. Four of 66 patients (6%) had clinical gen flow of 15L/min, would require 3 “D” cylinders of oxygen
deterioration during flight that may have been the result of an for a 45-minute flight when loading/unloading times and pos-
expanding pneumothorax. All four were successfully managed sible flight delays are considered.
with NDC. 85
Destroyers do not carry medications for rapid sequence intu-
Carrier-based helicopters typically fly at altitudes between bation, since that intervention is one that neither the IDC nor
500 and 2000 feet, depending on the mission and the threat the junior corpsmen on board are likely to be proficient in.

TCCC Maritime Scenario: Shipboard Missile Strike | 23