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We report the use of the Asherman chest seal as a stabilisation device for needle thoracocentesis in the prehospital environment. Although this piece of equipment has been available for five years, primarily for the prehospital treatment of chest wounds,1 this novel modification of its purpose increases its application to prehospital care. This work was prepared on behalf of the research and developments committee of the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh.
The driver of an articulated lorry was heavily trapped in wreckage after his vehicle was involved in a collision with the rear end of a lorry laying out cones. Examination at scene revealed a left sided chest injury, possible intra-abdominal injury, and probable fractured pelvis. After extrication, the patient's condition suddenly deteriorated and his level of consciousness decreased (Glasgow Coma Score (GCS) 14 to 3). He was found to have paradoxical movements of his chest, absent radial pulse, no pulse oximetry reading, and the ECG tracing showed a sinus tachycardia of 124 beats per minute. Diagnoses of tension pneumothorax or cardiac tamponade leading to the pulseless electrical activity (PEA) were suspected and a Cook emergency pneumothorax drain was inserted with the release of air and dramatic improvement in the patient's condition. The immediate care doctor placed an Asherman seal onto the chest wall with the body of the plastic cannula stabilised within the flutter valve mechanism of the seal. The patient was transferred to hospital with a GCS of 14, radial pulse 120 beats per minute, blood pressure 110/70 mm Hg, and pulse oximetry 95%.
The patient subsequently had a chest drain in the accident and emergency (A&E) department, before computed tomography and laparotomy for a hepatic injury. The Cook drain and Asherman seal were kept in place throughout these procedures and transfer to intensive care.
A 17 year old man was a non-restrained front seat passenger, trapped in a car after a collision with another vehicle. His airway was clear. He appeared to have decreased breath sounds and an increased percussion note on one side of his chest although this assessment was difficult in a noisy environment. He had a GCS of 12 at scene. During extrication he deteriorated and required bag-valve-mask assisted ventilation. He developed increasing respiratory distress and he had clear signs of a left sided tension pneumothorax. A needle thoracocentesis was performed but was subsequently dislodged and needed replacing during the extrication. After this the venflon was stabilised in position using an Asherman chest seal, which then maintained the position until the completion of extrication and during the 10 minute transfer to hospital. In the A&E department a chest drain was performed and the patient subsequently made a full recovery.
Chest trauma is one of the leading causes of trauma deaths2–5 and tension pneumothorax is one of the immediately life threatening conditions amenable to prehospital treatment.6 Needle thoracocentesis, entailing the insertion of a large bore cannula into the second intercostals space in the mid-clavicular line, is an established treatment for this condition and buys time before definitive chest drain insertion in hospital.7 It is recognised that cannula length can be a problem in the thoracocentesis technique.8,9 Chest drain insertion outside of hospital can prolong scene time and is rarely immediately necessary in most trauma scenarios.
During extrication, patient packaging, and transfer, the needle thoracocentesis can easily be dislodged as the second case identifies. The Asherman chest seal can easily be placed over the barrel of the thoracocentesis cannula and permits a more robust, easy, and readily available stabilisation device for the thoracocentesis cannula than tapes, gallipots, and syringe barrels, which are currently suggested (fig 1 and 2).
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