It is well documented that many studies report high success rates for needle thoracostomy, but numerous others report inferior success rates to decompress the chest. Consequently, it is recommended to review training protocols for quality assurance and improvements based on a minimum of five factors: 1) Not using current recommended NDC equipment; 2) NDC not conducted in the correct anterior or lateral anatomical locations to achieve chest decompression; 3) Anterior NDC performed too medially with penetration inside the “cardiac box” resulting in an iatrogenic mediastinum injuries; 4) NDC device failures such as catheter clotting, kinking, dislodgement; 5) Not using recommended pediatrics NDC procedures
for anterior and lateral anatomical sites; and 6) Not using both low and high fidelity simulations to train practical teaching scenarios in the laboratory and field settings during intense day and night training using experienced trainers. CoTCCC recommends a cadaver-based NDC training program since this has been found to result in improved performance. Here are two TPX training videos that were developed to support the updated TCCC curriculum – NDC
and the other for chest seals
Implications for Wilderness Medicine Practitioners:
The robust principles of TCCC guidelines for managing a TPX are equally applicable to trauma victims in any civilian setting
. Previously, Lanny Littlejohn MD, a current CoTCCC member, made recommendations for managing chest trauma
in the wilderness setting as published in the Wilderness & Environmental Medicine 2017 Special Edition titled, “Tactical Combat Casualty Care: Transitioning Battlefield Lessons Learned to Other Austere Environments."
Norman McSwain MD
, a trauma surgeon, CoTCCC member, and the founder of NAEMT’s Prehospital Trauma Life Support program, would frequently remind us all during our CoTCCC meetings by stating to always exercise principles vs. preferences as a fundamental critical concept in prehospital trauma care. When in the backcountry, or in any other trauma setting, and when indicated, the principle is to effectively manage a TPX and decompress the chest in a victim with hypotension, shock, and traumatic cardiac arrest. The preference is what gear you will carry to manage chest trauma, and how you choose to achieve the objective, i.e., with an occlusive or vented chest seal, and a needle, finger, or a chest tube thoracostomy. Finally, to minimize unsuccessful chest decompression attempts, and related iatrogenic complications, a robust training program is essential with high fidelity simulation models, experienced mentors/trainers, and with a quality assurance oversight program. Otherwise, you are effectively “up a creek without a paddle”, especially in a limited resource environment.