View Full Version : Occlusive dressing use by civilians
I was at a CERT (Community Emergency Response Team) first aid refresher last week where we reviewed the use of tourniquets and the newer types of bandages. I realized my FAK is a little outdated and that it wouldn't hurt to update it with some OLAES bandages and maybe a few other things.
In looking at the various threads on FAKs, blow out kits, GSW kits and the like there is a fair amount of discussion around occlusive dressings, Nasopharyngeal airways, and cath needles in kits.
My background is Red Cross first aid and CPR training and CERT training which deals with triage and basic first aid. I would like to take the Red Cross Wilderness First Aid class but do not plan to get any more advanced than that.
Based on my level of training I would never try to use a cath needle to do a decompression or try to insert an NA. My question is around occlusive dressings. If you have someone with an obvious "sucking chest wound" where there is clearly air moving through the injury and help is 30 or more minutes out, should an occlusive dressing be applied? It seems the potential complications are much more than putting pressure on a bleeding wound.
Thanks.
nineteenkilo
11-09-12, 13:55
It really depends on the exact scenario. Could you be a little more specific about the scenario to which you are referring?
Sure. And let me know if I leave out something important.
The most likely scenario - and I wouldn't consider these very likely in the first place - is out shooting with friends or my son's scout troop. We usually end up out a forest service road in the mountains with no cell phone coverage. The scenario would be someone gets careless and shoots someone else with a high velocity rifle round in the chest causing a wound large enough to create a defect in the chest wall that allows free flow of air into the chest and undetermined internal injuries.
My goal would be to send someone to call 911, provide first aid, and possibly move them closer to a the main road. I would be assessing the ABCs and applying dressings and pressure to bleeders. If there is an exchange of air, would it be better to put an occlusive dressing over the wound given that EMTs are roughly 30 minutes out and a trauma center even longer or would it be better to just bandage it and leave it at that.
In monitoring the ABCs if breathing was becoming more difficult I would assume I would try to burp the dressing and reseal when the person exhales. However, from the reading I've done it sounds like you really should be far better trained to diagnose a tension pneumo, etc.
In the CERT realm I would expect more closed chest trauma from crush injuries and in that case it would be get them to professional help ASAP. There would most likely be fire and EMT nearby anyway.
If I'm leaving out something important let me know.
Thanks.
Apply occlusive dressing. It is only contraindicated for injuries to the nose and mouth. ;) Current trend is for fully occlusive dressings without any valve. Protocol is to burp dressing if needed before performing a needle decompression.
Get your EMT-Basic cert. There are numerous schools that have a Wilderness Training/EMT-B Program.
nineteenkilo
11-09-12, 23:11
Apply occlusive dressing.
Get your EMT-Basic cert. There are numerous schools that have a Wilderness Training/EMT-B Program.
This sums it up nicely. :)
Thanks gentlemen. My brother-in-law was in an EMT program of some type so I will ask him about schools in the area.
This is more of a Paramedic level scenario. An EMT-B course won't teach you past the occlusive dressing. Darting a chest without proper training would be a very last resort if your patient is about to suffocate. The EMT-B course however will help you to understand what is going on physiologically with a pneumo/ hemopneumothorax. I would suggest as a preventative measure going over safety with everyone and working through what you are going to do before commencing live fire.
calicojack
11-10-12, 06:24
This is more of a Paramedic level scenario. An EMT-B course won't teach you past the occlusive dressing. Darting a chest without proper training would be a very last resort if your patient is about to suffocate. The EMT-B course however will help you to understand what is going on physiologically with a pneumo/ hemopneumothorax. I would suggest as a preventative measure going over safety with everyone and working through what you are going to do before commencing live fire.
actually the current NREMT curriculum does in fact teach about occlusive dressings, and (at least in my state) EMTs are allowed to use such devices
actually the current NREMT curriculum does in fact teach about occlusive dressings, and (at least in my state) EMTs are allowed to use such devices
At first blush I interpreted the post the same as you, re-reading, he was talking about skills after occlusive dressing.
calicojack
11-10-12, 16:29
At first blush I interpreted the post the same as you, re-reading, he was talking about skills after occlusive dressing.
your right. he was. my bad. i guess i missed the word "past"
Sealing a sucking chest wound is a basic skill and EVERY EMT-B should be proficient in this skill.
The opening in the chest wall needs to be 2/3 the diameter of the trachea to allow significant air in to the thoracic cavity.
The opening in the chest wall needs to be 2/3 the diameter of the trachea to allow significant air in to the thoracic cavity.
I'm sure you mean pleural cavity. ;)
Use the occlusive dressing, standard for penetrating chest trauma. Remember that injuries from the belly button up should be treated as potential thoracic injuries.
The risk of developing a tension pneumothorax increases if a piece of tissue functions as a valve, allowing air in but not out.
I'm sure you mean pleural cavity. ;)
Use the occlusive dressing, standard for penetrating chest trauma. Remember that injuries from the belly button up should be treated as potential thoracic injuries.
The risk of developing a tension pneumothorax increases if a piece of tissue functions as a valve, allowing air in but not out.
Yeah. Was flipping through the chapter on Thoracic Trauma. I shoulda been more specific.
Your post reminded me of something an instructor said during AMLS in regards to "sick" patients. "Pain anywhere between neck and navel should be suspected of being cardiac in nature until ruled out."
Great quote, I'll remember that one. I mis-assessed a patient once complaining of pain in his abdomen--and attributed it to his recent (2 days) gall bladder surgery, and the fact that his incision appeared to be infected. Of course, the guy failed to mention that he had pain in his chest, or that it was radiating to his shoulder (until he told his wife later, and she took him to the ER).
Some people's kids, I tell ya.
But back on topic--the above recommendations all hold. Occlusive dressings are not contra-indicated, and there's no reason why a first aid guy (or even plain untrained civilian) can't slap one on. Thoracentesis, yes, that would be a problem--don't try that!
It worries me that I see a ton of guys talk about putting those in their IFAK; it's a good way to cause more harm than good, with some over-zealous responder lacerating a heart, or needling the wrong side, and going to jail for a while.
Also, why no naso? It really is about the most simple device ever. Lube, bevel towards septum, push gently but firmly, too easy. If they can teach every Tom, Dick, and Jane in the Army to use a naso, chest seal and NCD you can do it too.
Thoracentesis, yes, that would be a problem--don't try that!
It worries me that I see a ton of guys talk about putting those in their IFAK; it's a good way to cause more harm than good, with some over-zealous responder lacerating a heart, or needling the wrong side, and going to jail for a while.
While I agree that untrained personnel should not perform a needle decompression, I think that the procedure is made out to be more complicated than it is.
TCCC guidelines recommend a lateral approach, going in through the 4th or 5th intercostal space along the midaxillary line. Much higher chance of the procedure succeeding, and much less risk of lacerating/puncturing the heart than decompressing along the midclavicular line.
Indicators are not that complicated (dyspnea, tachycardia, tachypnea, chest pain, low blood pressure, deviated trachea, distended jugular veins), and if you puncture a person who does not have a tension pneumo, you can accidentally give him a pneumothorax.
Isn't that a better outcome than not decompressing a pt, who dies because first responders didn't get there in time?
Read and understand your states Good Samaritan law. While you while be safe with just sealing a chest with a chest seal. Needling aka decompressing a chest is a wholly different matter that requires documented training and a active physician adviser who authorizes you to decompress a chest, in most every state that I have looked at, to prevent you from being charged with the felony of practicing medicine without a license. Also you would also be liable civilly as you have also violated the Good Samaritan law.
I have treated many dozens of patients with GSW to the chest who did not require emergent decompression of their chest. The time frame of treatment was mostly within 90 minutes of wounding to arrival at a trauma center. While these patients will require a chest tube to be placed prior to surgery, they did not require emergent decompression of their chest.... But I have had a few GSW's that also did require decompression of their chests, but this is a much smaller number of patients, several of them still went on and died, despite our best efforts to save them and also having very rapid access to level one trauma centers.
Let's be honest about the situation in penetrating trauma a TPX does not form quickly in a spontaneously breathing patient. Even if you suspect a TPX is forming and you have an occlusive dressing in place to seal the PT's chest, you can always peal the dressing back and wait for the Pt to begin to exhale prior to resealing the chest, to reduce the intrathoracic pressure and buy the patient more time. Once you preform an endotracheal intubation (this could possibly also happen with a King Tube) on this PT to protect their airway a simple pneumothorax will tension with in a few minutes.
One thing that mimic a TPX where decompressing the chest could cause serious additional injury or death to the patient is a traumatic herniation of the diaphragm. The last thing that you want to accidentally do is place a large needle into the liver when it was herniated into the chest of a patient.
The other thing to remember is that even with the BEST surgical care prepped and ready to go watching a patient get shot in the thorax, there is still a good probability that this patient will die.
Caring for a member of the US Military while in the Military is one thing, you can get away with a lot in this setting. If you are a lay person, FR, WFR, EMT-W, EMT-B et al, please seal the PT's chest with an occlusive dressing; I would strongly advise you against decompressing a chest of anyone in a civilian setting in America as you will be opening yourself up to legal problems. Without a waver and additional training that is approved by the physician adviser for your service, decompressing a chest as an EMT-B will land you in dangerous legal water as it is. If you are an advanced provider make sure that you have a signed agreement, with your physician adviser, to preform advanced skills outside of work to protect yourself from legal problems.
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