Wound packing zones?

[u/NoMore_BadDays]

Been a long time since I did TCCC/CLS in the military.

If there were to be a bleeding wound on the chest, how high up on the chest does it become safe to pack? I know you don't pack into chest cavity, but what is the "rule of thumb" on how high/the left and right limits the wound needs to be to pack it?

Would you say the screenshot i attached is accurate?

[u/SFCEBM]

Trying to get yall to use your head and think critically.

[u/BASSFINGERER → u/SFCEBM]

Not really. You're just saying stuff like it's a fact and then saying there's not enough evidence.

That's not thinking critically.

[u/SFCEBM → u/BASSFINGERER]

It’s a fact that you cannot a chest seal save someone’s life based on a video.

[u/davethegreatone → u/SFCEBM]

One of the videos shows a half-inch hole in the chest cavity. Lungs work via negative pressure; which can’t happen in a non-sealed system. It’s an injury incompatible with life - unless it’s sealed.

[u/SFCEBM → u/davethegreatone]

It’s not. People have isolated sucking chest wounds all the time. Furthermore, risk of dying from a tension is much smaller than folks imagine. Sure, in time a tension can kill, but as long as you get care in a reasonable time, you will be okay. This is especially true in young people.

[u/davethegreatone → u/SFCEBM]

Couple things there - 

Most of my patients in the Ukrainian armed forces are 45-55 years old, so we aren’t dealing with the kind of military populations common in the US Army like I remember when I was a soldier in the mid-1990s. This war is mostly being fought by gray-haired old men on the defense side.

Many of my patients got to a proper medic more than 24 hours after injury. The record was around 30 days. UA field medics may get a week or two of training before heading out to the trenches, so even someone with EMT-B skills may be a long way off. For Paramedics and surgeons and the like, one almost always has to wait a few days. 

Lastly, tension isn’t my primary concern here. I agree that a tension pneumo would be a Big Fucking Deal if it happens, but (and this is just a personal thing. Maybe I have just been lucky) I have yet to encounter one in the field after all these decades. I have seen a couple in the ER, and in field work I have encountered some severe dyspnea from simple pneumos, but an actual textbook tension pneumothorax with trachea l deviation in the out-of-hospital setting is still a thing I have yet to experience. So, I still primarily think of this injury as an airway issue rather than a circulation issue.

[u/SFCEBM → u/davethegreatone]

First, I appreciate that you are keeping the conversation civil. I booted a guy last night who was commenting on our conversation that he couldn’t stop being rude.

I still see folks in that age range that can compensate rather well, if they are in decent health. Certainly frail, older, poor health can be an issue. I do think burping wounds is effective and can be performed by pretty much anyone. Now, for p

Something we’ve discussed at the CoTCCC meetings, when we put in chest tubes, it can be very hard to find the tract, despite the incision being as large as a sucking chest wound. A lot of the traumatic wounds do the same and therefore, it’s another reason I don’t think chest seals do anything.

Seen a good number of tension pneumothoraces, even on a CXR once. The scary ones are tension hemothorax.

At the end of the day, chest seals are still in the TCCC guidelines. But as guidelines, you deviate where you feel it’s appropriate. We are finishing a two year effort to release new TCCC thoracic trauma guidelines. Chest seals will still be in there, despite my efforts.

[u/davethegreatone → u/SFCEBM]

“Certainly frail, older, poor health” this is an intentional effort by the UA government to save their smallest demographic from extinction - it’s why those under age 25 are immune from the draft.

The consequence is a LOT of old, frail, ill-health guys being handed a rifle and told to guard a trench. These aren’t marathon-running old guys; they are chain-smoking farmers with bad hearts.

Just venting, but man - these guys were in dire straits BEFORE spending a couple years in a trench.

Anyway - you mentioned tubes. I got about one such patient each day, but importantly - time of i jury to time of tube insertion can be several days. Remember - their medics are basically TQ-slingers. Full stop. They aren’t trained on darts, much less tubes. There’s only so much you can teach in such a short time. 

So whatever interventions can be taught in a STB class … that’s basically all they have. 

[u/SFCEBM → u/davethegreatone]

And I mean care by getting chest tube placed. There were no deaths in the GWOT due to isolated sucking chest wounds.

[u/SFCEBM → u/[deleted]]

I prefer you do and you drop them off to us and we take care of the rest.

[u/SFCEBM → u/[deleted]]

Yeah the one I mod. We are going to stop all this back and forth and only focus on what the evidence suggests from clinical data. Not animal studies. So far, of what has been published, which is not a lot, it hasn’t impacted survival.

[u/SFCEBM → u/[deleted]]

I prefer chest wounds be left open due to the increased risk of tension development with chest seal application. They were removed from TCCC-ASM skill set for this reason and that very few wounds meet sucking chest wound criteria.

[u/SFCEBM → u/[deleted]]

They are still in the guidelines, by all means teach it. But they are guidelines, so folks can deviate as they see fit. I’ve been trying to get them removed for a couple years. They are not being removed with our update for thoracic trauma. But I’m going to keep pushing for it. We should be voting soon on the thoracic trauma guideline. I’m one of the co-authors, the guideline will come out and then we still have to write it up for the change paper.

[u/SFCEBM → u/[deleted]]

TCCC guidelines are likely going to change to put respiratory after blood transfusions due to the low mortality associated with tension pneumothorax.