Traumatic Tension Pneumothorax And Your IFAK

 As promised/requested:

From Comments on an unrelated post last week, I was referred to, and requested to comment on, a specific medical advice post at The Firearms Blog:

Which we'll get to momentarily.

But first, let's review a few things, to set the table for the discussion that follows.

I. Tactical Combat Casualty Care

TCCC was originally developed jointly by SF Medical and NSW (Army Green Beret and Navy SEAL medics, for civilian pogues), by both their team medics and medical staff, shortly after Gulf War I and before Gulf War II and A-stan operations, and was rolled out as a military SOF medical course. The original concept was to identify the most frequent causes of combat deaths that could be reduced by timely field treatment by field medical personnel, with minimal additional gear. Massive hemorrhage, airway occlusion, sucking chest wounds, tension pneumothorax, IV access/fluid resuscitation, and hypothermia/shock prevention were identified as the biggest payoffs in treatment for the least outlay in training and medical resources. The information, once disseminated among SF, was deemed far too good to restrict to just the high-speed low-drag types, and well within the scope of ordinary medics, and even average troops, and was subsequently adopted military-wide, and then by civilian elements, starting with law enforcement tactical teams, and from there, on to ordinary paramedics, EMTs, and trauma specialists throughout the civilian world. There are currently 42 voting members on the Committee on TCCC, who decide upon and frequently revise the TCCC guidelines, and they represent deployed specialists and doctors from all service branches. It has been regularly updated, and rigorously field-proven in practice in two decades of warfare in SWAsia in Iraq and Afghanistan. Its adoption and promulgation on a widespread basis resulted in a phenomenal and unprecedented reduction in killed-in-action deaths, casualties who died of wounds, and preventable combat deaths. You could look it up. In short, this is evidence-based trauma practice from the pointiest tip of the sh*tty end of the stick, not just a couple of guys just spitballing what-ifs and pulling stuff out of their ass.

Covering all of TCCC is beyond the scope of this post, but we've done so in the past in abbreviated form, 

TCCC I: Care Under Fire

TCCC II: Tactical Field Care

TCCC III: Tactical Casualty Evacuation

along with some other perennially needful things, and you should be familiar with it if you're in the military, own guns, or simply might get jacked up by some miscreant or random injury. In short, if you have a pulse, the nuts and bolts of TCCC should concern you deeply and personally.

For your edification, if you haven't already done so, you can (and should) download the entire current TCCC course free from the following link:

TCCC Guidelines - Nov 2020 ed.

Then read it, assemble the toys, watch the videos, and practice the skills, until they become second nature.

The military course for every Larry Lunchmeat (TCCC-ASM) in the dot-Mil is a total of 7 hours. 

The Combat Lifesaver course (TCCC-CLS) is 40 hours, geared for previously non-medical personnel.

The course for actual medical personnel course (TCCC-MP) is 16 hours.

None of those should kick anybody's ass to master, but it's your ass, and your time, so either learn it, or suture self.

II. Your IFAK Blow-Out Kit

The TCCC items that should be in your Individual First Aid Kit - IFAK (or elsewhere in your gear) would be: 

* a modern tourniquet (CAT-T or SOF-T recommended) - ideally as many as you have limbs, unless you figure you won't really need all of yours. At least one of them should be in the actual IFAK. The others can be anywhere in your gear. But if you think you need less, you're simply wrong, unless one or more of your limbs are already prosthetic. End of discussion.

* Any one of 57 varieties of clotting gauze and Israeli Bandage compression dressing(s)

* a  nasopharyngeal airway (AKA "nose hose") kit

* an occlusive chest seal (or actually, two, as many penetrating wounds tend to leave entry and exit wounds; or even more, as sometimes, you have more than one wound, or may be caring for more than one person)

* a chest decompression needle - or really, two to four, since it may take two pokes, and you have two lungs. (which item(s) is/are exactly the point at issue today)

* [for those for whom it's within their scope of practice and/or expertise, a cricothyrotomy kit, IV start kit, and appropriate IV supplies and antibiotics (that will be "NOT YOU" for 95% of readers here, so we ain't gonna cover any of that here)]

* a mylar casualty blanket (including a hypothermia headcap, if possible/necessary)

If you haven't got an IFAK that contains at least 6 of those 10 items already, you're just wrong.

And now, a few words about why this is germane today.

III. Tension Pneumothorax

First, basic lung anatomy:

Your lungs reside inside the pleural cavity (your chest), and they work as a bag-within-a-bag on each side (so our lungs don't rub up against your chest wall every time you breathe).

There are multiple non-traumatic causes for a pneumothorax, but we're only concerned today with the traumatic ones: penetrating or blunt, e.g. by gunshot wound(s) (GSW), explosive fragmentation, stabbing, one or more rib fractures, or blunt force (beating, motor vehicle accident, fall, explosive blast trauma, etc.). When something traumatically punches a hole (or holes) in your meat suit above the diaphragm, air can leak out of the inner sac (the lung) and enter the pleural cavity (the bags that the lungs sit in). This air is trapped, and cannot escape, and as more air gets inside the pleural cavity than inside the lung, the lung collapses. 

1. Besides the original trauma, this hurts. A lot.

2. It cuts down on your ability to transfer oxygen in and CO2 out. This gets worse by the breath, due to the ongoing hole.

3. This makes you breathe faster (tachypnea). Normal adult respiratory rate is between 12-20 breaths a minute. Anything over 20, by definition, is tachypnea.

4. Which makes your heart beat faster (tachycardia). Normal cardiac rate is 60-100 beats per minute. Anything over 100, by definition, is tachycardia.

5. This makes you feel short of breath (dyspnea), and somewhere between uneasy and full-on panicky. The worse you are, the worse this gets. This, in the immortal observation of Cliff Clavin, is called a "vicious circle".

6. As the punctured lung collapses, it pulls your trachea (windpipe) to the good side, pressing on the pericardial sac (where your heart lives). Which makes it have to work harder, which makes it beat faster, while oxygen transfer isn't occurring in 50% or more (your lungs are different sizes) of your respiratory tract, which makes it beat faster, and get behind, which backs blood up into your heart, which makes it beat faster, which makes blood back up upstream, especially coming down from your brain, which makes your jugular veins bigger on both sides. Which makes you more panicky, and more short of breath, and you can see the patient's trachea go from midline, and move over to the good side (tracheal shift). Meanwhile, your heart is not working properly, leading to low blood pressure (hypotension), and low oxygen exchange body-wide (hypoxia), and you're going into shock. See how one hole makes everything go to shit in a hurry?

Here it is in pictures, and a basic video:

Turn the volume off; there's no narration.

That should cover it, and anything simpler would require crayons. 

Now, we get to the rat-killing:

IV. The Post In Question

Ask Doc: Please Stop Carrying Chest Darts

I will adopt the format used by The Other Ryan, from his sadly departed blog, Total Survivalist Libertarian Rantfest, to wit:

A. The Good

That giant three-and-a-half-inch, 14 gauge needle is colloquially known as a “chest dart”, but is more appropriately a tool used to perform a needle thoracostomy to decompress overpressure from a tension pneumothorax (we will refer to this in shorthand as tPTX). First off, if you could not immediately define a tPTX per the last part of that previous sentence, that may be an indication that you have no business carrying that equipment.

Absolutely SPOT. ON. If there's anything in your kit you don't know WTF or HTF to use, either unf**k yourself, or get it out of your kit. There is no third option.

And then, after this certified brilliant observation, he goes into the guard rails.

B. The Bad

"A tPTX takes a long time to develop—like 30-40 plus minutes (even up to hours). Using signs like “tracheal deviation” and “jugular vein distention” means you missed the problem a long time ago. By the time you start having vital sign changes and cardiac problems, the condition is pretty progressed, and is also what makes it “tension”. The tension is what is causing the vital sign changes since unacceptable pressure is being applied to the heart and vascular structures."

Sorry, Slick, but no, it doesn't take a long time. It takes as long as it takes. Bigger holes make it happen faster. File this under Physics, and Duh! It can happen in as little as a few minutes after the injury, in fact. BTDT. Teenager with one punch from a 9mm, walked in under his own power, already in extremis after maybe 5-10 minutes, affected side had a partially collapsed lung. Chest tubed immediately. Oxygen sats immediately jumped from the high 80s to the high 90s. Don't have a trauma physician, Rx meds, wall suction, and a chest tube kit the size of a daypack? Might be a good idea to have a large-bore chest decompression needle then, wouldn't it?

"There are a few vital signs that may indicate a tPTX. Hypotension, hypoxia, subcutaneous emphysema, and tachycardia. For hypotension, you need to measure the blood pressure which means a blood pressure cuff and hopefully a stethoscope. For hypoxia, you really need a pulse oximeter (though cyanosis could be argued if you can rule out other causes). Tachycardia is easy to measure (and the pulse oximeter will do this for you as well).

Alongside that needle, do you also carry a stethoscope, blood pressure cuff, and pulse oximeter, in your IFAK?"

If you're the designated medic, you damned well better carry those items, and know how to use them. If, instead, we're going to use the most lazy and the stupid as the average person, the argument to dump gear becomes endless, and ends with the advice to simply suck your thump and hug your teddy, because anything else is out of your lane.

But c'mon, Doc, let's stop being stupid. I can diagnose tachycardia with one finger on a pulse, and a cheap Timex, in about 6 seconds. Even under the fireworks show at Disneyland, let alone in combat. I can use a calibrated eyeball and that same watch to diagnose tachypnea, same method: count for 6 seconds, multiply by 10. This is retard-simple. And while a pulse oximeter is fabulous for hypoxia, the most sensitive organ in the entire human body is the brain. If the patient is becoming more anxious, is diaphoretic (sweaty), and getting panicky, it's probably hypoxia and hypotension. Blue lips and extremities are worse, but even more simple, except at night. And if I can't find a pulse at the wrist, systolic pressure is below 80. If I can't find one at the groin/pelvic junction, it's less than 70. If I can't find one at the carotids, it's time to start CPR. I can tell all of that in about 2 seconds, with no BP cuff, and we both know none of this is news to you. One can piss and moan about ultimate accuracy, but if your standard of care is a fully equipped ER or nothing, why have a medical kit at all? That's a "shoot the wounded, and drive on" standard of care. So stop acting like this is Chinese calculus.

The indication for needle decompression in the field, far from CT, chest X-ray, or any other medical machinery, which is the whole point of TCCC, is if the patient is hemodynamically unstable. IOW, if they're breathing too fast, their heart rate is elevated above normal, their oxygen saturation is down, their blood pressure is dropping, or they have jugular venous distension (JVD) and/or tracheal shift. That's both WHEN and WHY you do needle decompression.

Telling me that needle decompression is bad because some people do it too often, too poorly, and/or too soon, means they don't understand that whole "clinical indications for therapy" part of the lesson, and/or haven't mastered the basic skill. That's a bad instructor/stupid medic problem, not a bad emergency technique problem.

C. The Ugly

"I would argue that someone that has the appropriate experience and training to CORRECTLY diagnose and decompress a tension pneumothorax, happens to be there at the exact time you need it, is willing to do the procedure knowing that they know will likely NOT be covered by insurance (or Good Samaritan laws), and also doesn’t have their own equipment is a Venn diagram of “not going to happen”.

Venn diagram I poorly drew showing the above scenario…

Or maybe you are running around the downtown of a large urban area (while wearing your plate carrier and carrying your IFAK) and a mass casualty occurs. Assuming you haven’t been detained by the authorities for looking out of place (unless there was an airsoft gear convention going on), you hop in and start helping. Nearby someone yells out that “I’ve got a tension pneumo here; anyone have a dart?”. Your cape unfurls, you rip open that IFAK, and chuck over that needle.

Tongue and cheek, yes, but seriously… Think through what actual scenarios you are likely to encounter and the probability of having a patient that will develop a tension pneumothorax and having another Good Samaritan on hand that can fix the problem."

Okay, that's the Captain Recockulous Strawman Version. Now, how about if I play?

i. Dumbass at the shooting range muzzle sweeps the line, and dumps a round into the guy two lanes over from you. After observing some other guy helpfully remove the pistol from Dumbass' hand and punch the shit out of him by way of getting his attention, you notice the guy on the ground has frothy bubbles of blood forming around that shiny new hole in his chest, and he's having some trouble catching his breath. But it's okay, you're out of cell service, it's only a five-minute run to the range shack phone landline, and the range is only 40 minutes from civilization. Think you might need a chest needle there, Butch?

ii. You're driving any one of a hundred lonely highways in BFE west of the Mississippi, and you're the first one to come upon the scene of an automobile accident, and you find the driver of the older car minus airbags somewhat the worse for wear, with a lot of chest pain, blue lips, sore ribs on one side from that steering wheel he slammed into when he hit the ditch, and his trachea is pointing to one side. Hmmm, good thing you left your tools at home because someone told you you'd never need them, right?

iii. Hiking with your friends, Jimmy takes a tumble down a slope, but fortunately, a large boulder to the chest arrests his further ass-over-heels progress after only 50-80 yards of tumbling. When you get down to him, he's panting for breath, he can barely talk, and he's got a lot of pain in the ribs on that side. What can the matter be?

Traumatic TPT doesn't require the Marines clearing Fallujah of dug-in Taliban to happen. Pretending otherwise is idiotic, or one has led a very sheltered life in trauma care.

And someone who acts according to the standard of a "reasonable person", within their level of training, is going to be completely covered under Good Samaritan laws in 50 states and seven US territories, just like with CPR or basic first aid. That doesn't mean you can't be sued, it means they can't win. In fact, failure to act may be prosecuted as criminal negligence if it was an accident you had a hand in accomplishing (like an auto collision), because at that point, you have an affirmative duty and legal obligation to render appropriate aid and summon help. Time and place are a factor, as is your level of training, and equipment available. The standard moves, depending on whether you're across the street from the fire station, or 50 miles out in the woods, two days' hike from the BFEgypt Community Hospital and Veterinary Clinic. So it depends on how much of a good guy (or douche) you are, at that point, and what's available for use.

"IT’S BETTER TO HAVE IT AND NOT NEED IT THAN NEED IT AND NOT HAVE IT…

I’d love a portable trauma suite fully staffed with trauma specialists, but the reality is…

In wilderness medicine, we discuss the concept of “Ideal vs Reality”. Ideally, I would like to have instant access to all of the specialized equipment I could and be able to deploy instantly as needed. The reality is that I can only carry a limited amount of stuff without looking like a crazy person (depending on the context) and drawing inappropriate attention. The reality is that I am likely to encounter only a small subset of known (and treatable) medical problems in normal life. 

100% of the people on the planet will experience cardiac arrest at least once. That doesn’t mean I carry an AED around with me everywhere.

I can think of many different things that would make my first aid kit long before a decompression needle. No one that has ever dealt with a traumatic medical emergency has ever said, “You know, I just had too much gauze available…”

Part of providing medical assistance is having good judgment. Good judgment includes understanding the injuries that are most likely to happen and having the ability to treat those injuries. Good judgment is also staying in your lane (within your training and experience).

IT DOESN’T TAKE ANY SPACE IN MY IFAK

You could fill an entire IFAK container with equipment that “doesn’t take any space”. Don’t let equipment serve the role of magic talismans that replace training and skills. The most important piece of equipment is your brain. Fill THAT with the ability to determine if a problem is serious or not serious and if the problem is getting better or worse.

In your IFAK, you should carry, at a minimum, tools to help you deal with IMMEDIATE life-threatening injuries. Injuries that will kill you right now. Tourniquets (a real tourniquet that applies mechanical advantage and is backed by science, not a fancy rubber band). Compressed gauze. Chest seals. Be wary of any kit that does not include those items."

Let's stop bullshitting here, Doc: chest decompression needles are the size of ink pens, and of similar weight. We're not talking about packing a CT scanner in your pack, or leaving behind the tourniquets and all the bandage gauze. Four of them take up minimal space, and weigh maybe 4 ounces. This is stupid easy and simple, for field reversal a simple but treatable life-threatening condition, which is the whole point of all of TCCC. And if you don't do it, they're probably just going to die. I vaguely recall in school hearing that that's bad, but I'm open to counter-discussion on that.

Tension pneumothorax is both life-threatening left untreated, and reversible with minimal equipment and training. And there's nothing else than can substitute for that chest decompression needle if you need it RFN. Many of us carry three pounds of loaded handgun, holster, and spare mag or so, FFS, every time we leave the house, even though needing it is literally a one-in-a-million situation. You want to pull out your crystal ball and tell me when I won't need that, too?

We can go back and forth, and I can knock over all the straw men (and that's about 90% of the blogpost) you've built for why you're right, and all the king's horses, TCCC, the committees that developed it, and thousands of medics and trauma docs, military and civilian, who think carrying a chest needle is a good idea are all wrong. But forget anything I say. Let's just look at go-to medical thinking, from someone far above both our pay grades: the author(s) of an authoritative professional medical text:

A tension pneumothorax is a severe condition that results when air is trapped in the pleural space under positive pressure, displacing mediastinal structures, and compromising cardiopulmonary function. Early recognition of this condition is life-saving both outside the hospital and in modern ICU. Knowledge of necessary emergency thoracic decompression procedures are essential for all healthcare professionals. Traumatic and tension pneumothoraces are life-threatening and require immediate treatment.

Patients with trauma tend to have an associated pneumothorax or tension pneumothorax 20% of the time. In cases of severe chest trauma, there is an associated pneumothorax 50% of the time. The incidence of traumatic pneumothorax depends on the size and mechanism of the injury. A review of military deaths from thoracic trauma suggests that up to 5% of combat casualties with thoracic trauma have tension pneumothorax at the time of death.

...hypoxemia, acidosis, and decreased cardiac output [from tension pneumothorax] can lead to cardiac arrest and, ultimately, death if the tension pneumothorax is not managed in a timely fashion.

 On examination, it is essential to assess for signs of respiratory distress, including increased respiratory rate, dyspnea, and retractions. On lung auscultation, decreased or absent breath sounds on the ipsilateral side, reduced tactile fremitus, hyper-resonant percussion sounds, and possible asymmetrical lung expansion are suggestive of pneumothorax. Symptoms of tension pneumothorax are more severe. With tension pneumothorax, patients will have signs of hemodynamic instability with hypotension and tachycardia. Cyanosis and jugular venous distension can also be present. In severe cases or if the diagnosis was missed, patients can develop acute respiratory failure, and possibly cardiac arrest. In some instances, subcutaneous emphysema can also be seen. The diagnosis of tension pneumothorax must be made immediately through clinical assessment as waiting for imaging, if not readily available, may delay management and increase mortality.

Initial assessment to determine whether the patient is stable or unstable dictates further evaluation. Emergent needle decompression or chest tube thoracotomy must be performed immediately if the diagnosis [of tension pneumothorax] is highly suspected."

Gee, chief, that's gonna be kind of hard if you left all 2 ounces of those two chest needles back home, because you thought you'd never need them, i'n'it?

"Tension and traumatic pneumothoraces are usually managed in the emergency department or the intensive care unit. Management strategies depend on the hemodynamic stability of the patient. In any patient presenting with chest trauma, airway, breathing, and circulation should be assessed. Penetrating chest wounds must be covered with an airtight occlusive bandage and a clean plastic sheeting. 

If the patient is hemodynamically unstable and clinical suspicion is high for pneumothorax, then immediate needle decompression MUST be performed without delay. Needle decompression is done at the second intercostal space in the midclavicular line above the rib with an angio-catheter."

They sound pretty sure of themselves, don't they? But what do doctors and medical school professors know about this? Oh, besides all that medical school, and stuff...

Tom R. (the author of the offending post at The Firearm Blog) may be a helluva field medic. But his advice on this subject is tainted by advocacy with a dearth of authority or common sense behind it, and a surplus of logical fallacy and just plain silliness.

Should untrained Jaspers try needle decompression? Hell no!

If you're an idiot, or simply too lazy to learn the skills, by all means, leave out the chest needles. You don't need them, for a certainty. If the audience at The Firearms Blog is a bunch of lazy idiots, then the post is solid gold sound advice. I don't know them, so I cannot say.

If you're not an idiot, and you're going to pack the gear, you'd better damned well know the pathophysiology of this cold, understand the correct procedure (which we have not gone into in depth here, but which takes less than 3½ minutes to learn), have practiced and demonstrated same correctly under competent training and preceptors, and be able to explain in excruciating detail why you did or didn't do it multiple times in a court of law afterwards.

Stabbing someone in the chest is a lot like shooting people, in that respect. You're going to be talking about it afterwards, and not in a comfortable "There-I-was" way. Bet. On. That.

But the medical literature - nearly all of it - is 180° out from Tom R.'s dubious advice. You're packing your own kit, and neither he nor I are holding your hand when you do that. You're going to have to use your own head (brains optional but highly recommended), and trust your gut. But as Murphy's Laws Of Combat informed you, "Anything you do, including nothing, can get you or someone else killed".

But if you need to do it, in either the case of shooting someone, or needle decompression, explaining that you left the gear home because someone on the internet told you that you'd never need it isn't going to help much, and somebody is liable to suffer death or serious injury because of your lack of foresight.

If medical stuff is too hard for you, don't do it. You won't hurt my feelings. But if it's not, learn the things that can actually make a constructive difference, carry the gear to do them, practice the skills, regularly, and be prepared, intellectually and emotionally, to suck it up and do them if the need arises. Chest trauma is rare, but certainly not beyond the realm of possibility, even in everyday peacetime situations. And tension pneumothorax in the presence of chest trauma is pretty common, and the actual medical literature is clear: prevention of death is a lot easier on the patient if you don't wait until the last second, and they're in cardiac arrest, because you dithered. Suggesting that standard is flatly asinine, and contrary to every precept of trauma medicine. I'm going to go with that advice, and leave the advice found in this editorial turdburger right where I found it. Particularly when we're talking about carrying something the size and weight of ink pens.

If that's too much extra gear to carry, maybe skip the whole first aid kit, and just carry a rabbit's foot, right?

The author at TFB may have any number of good and well-thought out posts on medical advice for Joe Average. But the example referred to me is NOT one of those, and for the reasons set forth above, we consider it really, really bad advice. And if you look at his closing comments, it seems he knew from the outset he was jumping hard on his wedding tackle with cleats on, and expecting exactly the response I've given. One can only ask, "Then why do it?" For reasons passing understanding, some people are masochists, we suppose.

The whole post reviewed, on reflection, sounds exactly like the cinematic chin-wagging from gold-plated Ranger battalion geniuses who told Grimes in Blackhawk Down that he wasn't going to need water, NOD, or trauma plates(@01:32ff).

So, how'd that "wisdom" work out when tested?

Learn and live.

If anything in this left a mark on anyone, we commend to their usage a certain ointment.