Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXVIII: Wounds and Injuries of the Chest
United States Department of Defense
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What therapeutic interventions can be undertaken is determined by the echelon of care. What echelons will be used depends in turn upon the pathway of evacuation. Casualties may be evacuated directly from the battlefield to surgical facilities, or they may pass through progressive echelons of increasingly sophisticated care. Regardless of the evacuation pathway, the medical officer at any echelon is unlikely to do any harm if he does the following:
Surgical and radiographic facilities are not available in battalion aid stations. Therefore, treatment of chest wounds at this echelon must be limited to first aid and lifesaving interventions. These are best addressed in terms of the Advanced Trauma Life Support (ATLS) course's priorities which are, of course, applicable to all echelons of care.
Relief of upper airway obstruction is assigned first priority. The great majority of combat casualties with upper airway obstruction have either massive trauma to the face or a severe brain injury. It is quite clear that both nasal and oral endotracheal intubation in the former population is likely to prove quite difficult. Thus, most casualties requiring airway control will need a surgical airway or an oral airway. A description of the technique for performing either a cricothyroidotomy or tracheostomy is found in the chapter on neck injuries. It is necessary at this point to comment about cervical spine control. Penetrating cervical cord wounds in salvageable combat casualties are quite unusual. It is essential that misplaced concern about aggravating a possible cervical cord injury should not interfere with life-saving care for real problems.
Second priority is accorded to correcting respiratory problems. At the unit level, this will mean first and foremost inserting an intercostal drainage tube by means of a closed thoracostomy or, much less commonly, dressing an open chest wound. The casualty with a tension pneumothorax is most expeditiously managed by first venting the hemothorax by inserting a large-bore needle (14 gauge) through the second intercostal space. A chest tube should then be inserted. The technique for inserting a chest tube is described in the chapter on multiple injuries. The essential feature is to make an incision in the chest wall sufficiently large to allow entrance of a finger. By so doing, one assures that the chest tube is in fact placed within the pleural space. The large hole also assures that a chest tube of optimal caliber (40-45 Fr.) can be inserted. Sites for insertion are usually the fifth intercostal space midaxillary line or the second intercostal space midclavicular line. A closed thoracostomy utilizing a trocar is a useful alternative to the above, although the size of the chest tube may be insufficient to allow adequate removal of blood and clot. A chest tube should not be inserted through the missile tract. The chest tube should be secured to the patient and connected to a flutter valve such as the Heimlich.
Third priority is assigned to the management of bleeding and shock. Little can be done for the thoracic casualty in shock at this echelon other than to start an intravenous infusion of crystalloid fluid through two or more large-bore catheters.
Given a tactical situation in which direct aeromedical evacuation from the battlefield to surgical treatment facilities is not possible, the fundamental contribution of the unit level to the medical care of the thoracic combat casualty will be to prepare the casualty for safe evacuation to a definitive care facility. From the practical standpoint, this means that casualties with penetrating missile wounds of the chest that are clearly not superficial should have chest tubes placed. Ancillary interventions must include the administration of a potent antimicrobal agent and relief of pain if indicated.
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