# Occlusive dressings



## MotorCity (Jul 1, 2011)

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


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## Combat_Medic (Jul 1, 2011)

My go to improvised occlusive dressing is an MRA package.  There are always plenty of them laying around.  But thats just the military way.


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## boingo (Jul 1, 2011)

vasoline gauze and the foil packaging it comes in.


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## usafmedic45 (Jul 1, 2011)

I've just always used the wrapper off of a 4x4".  It's generally water-resistant enough to work and you tend to have ready access.


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## lightsandsirens5 (Jul 1, 2011)

It takes a second and a pair of scissors, but the oxygen reservoir bag from an NRB has worked great for me.


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## DesertMedic66 (Jul 1, 2011)

Pretty much anything that can make a tight seal. A glove, 4x4 dressing paper, O2 wrapper, etc.


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## MrBrown (Jul 1, 2011)

Defibrillation pad


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## DesertMedic66 (Jul 1, 2011)

MrBrown said:


> Defibrillation pad



Had a bird shot to the chest patient. We used EKG patches to seal all the holes. The nurses looked at us weird when they saw the 10 patches all around the guys chest.


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## AlphaButch (Jul 1, 2011)

Combat_Medic said:


> My go to improvised occlusive dressing is an MRA package.  There are always plenty of them laying around.  But thats just the military way.



think you mean MRE right? lol

Pretty much used whatever was handy and would seal. Torn piece off my poncho, MRE packaging, etc. 

The one time I thought I'd have to get real creative, I was reaching for my pack of cigarettes to use the plastic outer wrap but one of the line medics had an actual seal handy.

Haven't had the occasion to use one here in the states, but I have a Bolin seal on the truck.


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## mycrofft (Jul 1, 2011)

*My ex-Ranger buddy said his doc used a bloody sock once.*

Can't get much less commercial than that.


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## 18G (Jul 1, 2011)

The clear plastic backing to some trauma dressings (packaging) would work well.


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## Cawolf86 (Jul 1, 2011)

Our rigs have vaseline dressings I just throw on with the foil and tape it down. There are also Asherman chest seals, but I have never opened one up.


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## Combat_Medic (Jul 2, 2011)

AlphaButch said:


> think you mean MRE right? lol



Yea thinks.  MRE.  Don't know how I messed that one up.  I've seen a medic use the cigarette plastic on a sim man in training once.


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## usafmedic45 (Jul 2, 2011)

firefite said:


> Had a bird shot to the chest patient. We used EKG patches to seal all the holes. The nurses looked at us weird when they saw the 10 patches all around the guys chest.



Eh, I would have looked at your funny too....unless it's bigger than a dime or actively bubbling air, you really have no reason to put an occlusive dressing over it.  Generally things under the that size (roughly two-thirds the size of the lumen of the trachea) tend to not have sufficient surface area to truly pose a threat.


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## RocketMedic (Jul 2, 2011)

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.


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## usafmedic45 (Jul 2, 2011)

> That's a bit dangerous- even small holes can be dangerous



Got anything to back that up?  Now, if that hole is backed up by a lacerated mainstem bronchus, it is dangerous but because of the underlying injury not because of the hole.


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## HotelCo (Jul 2, 2011)

usafmedic45 said:


> Eh, I would have looked at your funny too....unless it's bigger than a dime or actively bubbling air, you really have no reason to put an occlusive dressing over it.  Generally things under the that size (roughly two-thirds the size of the lumen of the trachea) tend to not have sufficient surface area to truly pose a threat.


Wouldn't multiple holes that equal a greater surface area when combined pose a problem?


Sent from my iPhone using Tapatalk


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## DesertMedic66 (Jul 2, 2011)

usafmedic45 said:


> Eh, I would have looked at your funny too....unless it's bigger than a dime or actively bubbling air, you really have no reason to put an occlusive dressing over it.  Generally things under the that size (roughly two-thirds the size of the lumen of the trachea) tend to not have sufficient surface area to truly pose a threat.



Only 2 of the holes were actively bubbling. But just as a precaution we threw on more occlusive dressings over all the holes.


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## Cup of Joe (Jul 2, 2011)

Could always use the little bags that NRB and NC comes in.


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## MotorCity (Jul 2, 2011)

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?


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## TransportJockey (Jul 2, 2011)

MotorCity said:


> 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.


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## usalsfyre (Jul 2, 2011)

TransportJockey said:


> 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.


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## TransportJockey (Jul 2, 2011)

usalsfyre said:


> 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.


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## usalsfyre (Jul 2, 2011)

TransportJockey said:


> 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.


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## TransportJockey (Jul 2, 2011)

usalsfyre said:


> 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


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## usalsfyre (Jul 2, 2011)

TransportJockey said:


> 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....


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## mikie (Jul 2, 2011)

*any size would work...*



MotorCity said:


> 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.


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## usafmedic45 (Jul 2, 2011)

> 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.


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## Combat_Medic (Jul 3, 2011)

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.


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## usalsfyre (Jul 3, 2011)

usafmedic45 said:


> 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.


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## mycrofft (Jul 3, 2011)

*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.


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## emtchick171 (Jul 15, 2011)

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.


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## Too Old To Work (Jul 15, 2011)

Rocketmedic40 said:


> 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.


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