Occlusive dressings

[TransportJockey]

Completely sealing the hole (electrode) does no good for the patient. During exhalation air will be pushed between the lungs and chest wall. Right?

I've always used the vasoline 3x3 and foil wrapper. But can air escape that well enough?

Not really... that's why you tape three of the four sides so you can burp the dressings. That's why I'm not a big fan of defib pads or electrodes to cover SCW.

 

[usalsfyre]

Not really... that's why you tape three of the four sides so you can burp the dressings. That's why I'm not a big fan of defib pads or electrodes to cover SCW.

I'm pretty dang dubious that "burping" the dressing has a shot in hell of working. Just put a needle in if it shows signs of tensioning.

 

[TransportJockey]

I'm pretty dang dubious that "burping" the dressing has a shot in hell of working. Just put a needle in if it shows signs of tensioning.

Hey, best I can do is burping it And I'm not sure it's worked too well in the few SCWs I've had, but I've not had one develop a full blown tension pneumo yet.

 

[usalsfyre]

Hey, best I can do is burping it And I'm not sure it's worked too well in the few SCWs I've had, but I've not had one develop a full blown tension pneumo yet.

Got it. I really don't know why needle thoracostomy (at the 2nd midclavicular) isn't a Basic level skill. Absolutely life-saving, low risk of untoward side effects and about as hard as missing an IV.

 

[TransportJockey]

Got it. I really don't know why needle thoracostomy (at the 2nd midaxilary) isn't a Basic level skill. Absolutely life-saving, low risk of untoward side effects and about as hard as missing an IV.

Hey I could do it at my last service in TX. But NM says medic only skill ATM. Maybe if I get back to TX (fingers still crossed for MCHD) I can talk the medical director into letting me

 

[usalsfyre]

Hey I could do it at my last service in TX. But NM says medic only skill ATM. Maybe if I get back to TX (fingers still crossed for MCHD) I can talk the medical director into letting me

Heck, they teach it to soldiers in the CLS course. Yet most places won't let Basics or Intermediates perform what is absoultely a life-saver. But how much time does Basic class spend on spinal immobilization? Stupid....

 

[mikie]

any size would work...

What are some different materials have you used to make a good/effective occlusive dressing? No commercial devices please.

500mL NS bag, ditched the the fluid on the road* and cut a nice custom sized dressing.



*Not while the vehicle is moving.

 

[usafmedic45]

I really don't know why needle thoracostomy (at the 2nd midclavicular) isn't a Basic level skill. Absolutely life-saving, low risk of untoward side effects and about as hard as missing an IV.

I suggest you e-mail Ken Mattox and ask him about that. You'll get an earful. Do you really want to give basics anything sharper than a tongue depressor, especially when it's a low-frequency skill (in 15 years, I've done it less than 10 times that weren't just the "Eh...he's dead but let's try this anyway" sort of response) that has a fair amount of data says that it's frequently ineffective. Look at the data showing the fact that most angiocaths are not long enough in young males to reach the pleural cavities as well as the complication data coming out of the OEF/OIF medical experiences.

Heck, they teach it to soldiers in the CLS course.

There's a reason for that. Very few of us in civilian EMS see a vast majority of our trauma in the penetrating form. Honestly, they are actually looking at downplaying it in the TCCC and CLS training because of the number of cases where it was done without the existence of a pneumothorax to begin with.

 

[Combat_Medic]

I haven't heard anything about anyone down playing it in TC3 or CLS. I'll keep a look out for new info. I'm teaching another CLS class next week.

 

[usalsfyre]

I suggest you e-mail Ken Mattox and ask him about that. You'll get an earful. Do you really want to give basics anything sharper than a tongue depressor, especially when it's a low-frequency skill (in 15 years, I've done it less than 10 times that weren't just the "Eh...he's dead but let's try this anyway" sort of response) that has a fair amount of data says that it's frequently ineffective. Look at the data showing the fact that most angiocaths are not long enough in young males to reach the pleural cavities as well as the complication data coming out of the OEF/OIF medical experiences.

I'd be interested in seeing some complication data. I have seen the data stating the typical 3.25" angiocaths aren't long enough, that's why I personally like the Cook kits.

In ten years I've done it exactly twice. Both of which were iatrogenic in nature. So it is very low-frequency. But when you need it there's not anything less invasive that will fix the problem and if you don't fix it death usually follows shortly. As far as basics and tongue depressors...I'm not sure how to fix that issue. Even the new "national educational model" so undereducates these folks I'm not sure where to begin.

 

[mycrofft]

Comment about total diameter of all holes

Small enough holes do not pose anywhere near the risk (presuming they are not grievously positioned) then one large one because anatomic tension tends to close holes, not gape them open; if you have time to catalogue all wounds, nice, but the ones showing evidence of underlying serious impingement or penetration should get worked on first.

Not to say small defects should be totally ignored because of potential for fragmentation of projectiles (small cal slugs), or broken off penetrants (broken wood fragments, long lanceolate glass shards), or the entance of a small yet long penetrant such as a stilleto. Also, a small defect can trick you because the subject was positioned properly for it to create a small surface defect, especially if they are very obese. Surface defect doe not reliably depict penetrant size nand subsequent damage.

Does the defect bubble? Was the subject shot? Is there a fluctuant or very firm mass such as a hematoma around it? Breath sounds, abdominal auscutation (hearing air in gut? Etc.

 

[emtchick171]

There's several options to use "non-commercial" occlusives.

Like others have stated,the foil wrapper from a vasoline gauze, also we keep a roll of saran wrap on our ambulances, and sandwich bags work well also.

- - you may ask why we have sandwich bags, it is what we keep our laryngoscope blades in.

 

[Too Old To Work]

That's a bit dangerous- even small holes can be dangerous. Unless you're constantly monitoring every hole at all times, you always need to exercise basic preventative maintenance and seal the hole.

I've used a glove secured with gorilla tape. Gorilla tape works really, really well.

Usafmedic45 is right. It's really one of the great myths of EMS that every thorax wound needs an occlusive dressing. Or that you need to tape it on three sides. The patients I've seen that really needed that type of thing were so diaphoretic that tape wouldn't stick to them. Somehow, they never mention how that interferes with treatment.

From the lectures I've had from surgeons who have served in the military during the current wars, the two things that kill people with otherwise survivable injuries are exanguination from extremity wounds and airway problems. Which is where most of the teaching for field treatment seems to be right now for military medics. That, of course is from someone on the outside, hearing it from people on the inside.

For the record, the absolutely worst sucking chest wounds I've seen are from knife wounds, not GSW.