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Treatment for "sucking chest wound"

Posted: Fri Oct 24, 2014 8:57 pm
by acropolis5
I know that for many years the dressing of choice was a specialized chest seal bandage. Second best was a flat piece of plastic or foil, taped on three sides. But lately I've read that the latest medical thought was to put in place a completely airtight seal. Can anyone provide any further or better information concerning dressing such a wound, both at entrance and exit?

Re: Treatment for "sucking chest wound"

Posted: Sat Oct 25, 2014 1:41 am
by LJ126
Disclaimer: This is not medical advice. I am not a doctor. I'm just a lowly first responder. Please bear in mind that a trained medical practitioner may come in and offer corrections to my post, and by default should be taken more seriously than my comments on the matter.

There are several treatments for open pneumothorax ("sucking chest wound"), but it's important to understand what a sucking chest wound is so that the treatment makes sense.

Let's say your chest gets perforated by a stabbing injury. The hole in your chest act serve as the path of least resistance for inhalation, rather than through your nose and mouth. Sealing this hole completely will prevent air from entering the "plural space" of your chest cavity, and if performed immediately, you may be able to prevent air buildup. However, if enough air builds up and cannot be released, you may create a new situation by completely sealing the injury: tension pneumothorax.

So, if you've got to treat a sucking chest injury, you should try to leave a ventilation point. It should be fairly small (smaller than the trachea, "path of least resistance" thing), otherwise you can fail in the treatment of the open pneumothorax. This is why you seal the injury on three sides: (hopefully) keep air from coming in, but allowing it out.

Re: Treatment for "sucking chest wound"

Posted: Sat Oct 25, 2014 9:24 am
by DannusMaximus
Good article on such things from the Journal of Emergency Medical Services (JEMS). Linky: http://www.jems.com/article/patient-car ... -and-other

Here is a relevant excerpt, but the entire article is worth reading:

Another type of injury, sucking chest wounds, are a dramatic wound pattern with a fairly simple out-of-hospital treatment: placing an occlusive dressing on the chest wound. Early treatment of a sucking chest wound included placing an air-occlusive dressing over the site and taping it on three sides. It was thought that this dressing prevented additional air from entering the pleural cavity during inhalation and allowed trapped air to escape from the untaped edge during exhalation. However, the time required to apply this dressing and the limited effectiveness of the adhesive to stick to a diaphoretic bleeding patient often resulted in dressing failure.

Because of these difficulties, the Asherman Chest Seal was developed. This single-step dressing includes a tube with a one-way valve that extends from the center to allow air to escape—similar to the three-sided dressing but with a reduction in the amount of time needed for application. An alternative approach to this dressing is to simply place a defibrillator pad on the wound. Although it doesn't allow for escape of pleural air, the pad’s adhesive resolves the problems of too much time needed to tape three sides of the dressing and failure of the adhesive to stick to the patient’s chest wall. In some tactical settings, this simple approach combined with repeated needle decompression or occasionally “burping” the dressing, is preferred over the other dressing types.


Note that this article may be somewhat outdated - - publication date was August, 2013.

Anectdotally, the only time I've treated a confirmed sucking chest wound we basically piled a bunch of bulky dressings on top of the (big ass) hole in the man's side, and his respiration quality and O2 sats immmediately improved.

Re: Treatment for "sucking chest wound"

Posted: Sat Oct 25, 2014 9:33 am
by zXzGrifterzXz
Count me as another vote for what DannusMaimus said.

Secure the airway, seal the hole(s), and then move on to the next life threat.

Re: Treatment for "sucking chest wound"

Posted: Sat Oct 25, 2014 3:00 pm
by Neptune Glory
To deal with it quickly, the palm of a hand wearing a latex or non-latex glove pressed against the wound will prevent air from entering the chest cavity when the patient attempts to inhale air into his lungs.

Just keep the hand there until the ambulance arrives... that's about as much as I could hope for from any lay person.

EMT-Basics and EMT-Paramedics have other tools in the toolbox.
-Neptune, RN, EMT-Paramedic

Re: Treatment for "sucking chest wound"

Posted: Sun Oct 26, 2014 9:56 am
by medic photog
In my 37 years as a paramedic I've seen the treatment go back and forth from sealed to vented dressings several times. The bottom line is use an occlusive dressing o seal the wound and look for an exit wound, seal that too. I've used, seran wrap, defib pads, hands off defib electrodes, the bag a NRB comes in turned inside out- it's closer to sterile on the inside- and special purpose chest seals. IF they start to sow signs of a tension pneumo after the wound(s) are sealed, thing about popping their chest. In the real world, you probably won't be able to ascultate a difference in lungs sounds until they hit about a 10% pneumo. You'll see a difference in their ability to breath before you hear it.

Re: Treatment for "sucking chest wound"

Posted: Mon Oct 27, 2014 12:20 pm
by acropolis5
Thanx to all for your informative replies. I've read everything. I mistakenly posted my first reply in the next post down. That post lists my EDC Bag Trauma Kit. But I left out the 28 French nasal airway, that is also in the kit. "medic photog", for my layman's lack of knowledge, could you better explain " consider popping their chest". Thanx in advance.

Re: Treatment for "sucking chest wound"

Posted: Mon Oct 27, 2014 4:06 pm
by DannusMaximus
acropolis5 wrote: "medic photog", for my layman's lack of knowledge, could you better explain " consider popping their chest". Thanx in advance.
I think medic photog is talking about decompressing the tension pneumothorax using a hollow needle inserted into a specific area of the ribcage.

In a pneumothorax, air has leaked into the chest cavity and is preventing the lungs from fully expanding, causing respiratory distress. Inserting the needle allows the air to escape and the lungs to fully expand again.

A hemothorax is a similar situation, but blood or other fluids in the chest cavity is what is preventing full lung expansion.

If you don't like latin (pneumo = air/gas, and hemo = blood), think of pneumatic tools, which use air to power them. Any kind of trauma to the chest area (especially penetrating trauma) can result in a hemo or pneumothorax, but they can also develop spontaneously. The only one I've ever seen treated was a spontaneous pneumothorax which was treated in the ER I work at part-time. A needle decompression was performed on that one.

Performing a needle decompression is a generally a paramedic level skill in the civilian world, but is pretty routinely taught to military personnel, from what I understand.

Re: Treatment for "sucking chest wound"

Posted: Mon Oct 27, 2014 5:17 pm
by zXzGrifterzXz
DannusMaximus wrote:Performing a needle decompression is a generally a paramedic level skill in the civilian world, but is pretty routinely taught to military personnel, from what I understand.
One of my best friends just got done with Army Basic & MP School(He is an Army National Guard MP) and they made them learn how to "Needle D" during their combat life saver course. I found that interesting given its high placement as far as scope of practice in the civilian world but the military does that on many things.

Re: Treatment for "sucking chest wound"

Posted: Sat Nov 08, 2014 11:32 pm
by throwback
'll put out a summarized form of what I teach my guys. This is very much a layman's understanding, but it is what I need them to “get” if they are treating me, or need to treat each other in my absence.

This would be easier if my access to You Tube wasn't blocked....

The first thing to understand about the way your lungs work is that they are a vacuum system. The lungs are basically big, airtight sacks inside a variably sized container. When that container expands, the pressure inside it decreases, and the empty sacks take in air to equalize the pressure. When the container contracts, the pressure increases, and the full sacks empty in order to get back to a lower pressure. The first part of the container doing these expansions and contractions are the diaphragm, which expands about as far down as your belly button, and contracts all the way to the xiphoid process. The second part is the chest walls, that move in and out when we breathe. Both contribute to breathing in healthy adults all the time, but the diaphragm does most of the work when we are at rest.

By way of analogy, think of your thoracic cavity as not-totally-sealed Tupperware container. When it gets squeezed, you push air out of it, burping the Tupperware. When you release it, the air rushes back in. Same principle applies here.

In a healthy person, the airway is the only way for the air to go, and the airway directs the O2 into the lungs, where it belongs. However, as D. Maximus notes, air follows the path of least resistance. So, if you get a hole anywhere in the plural space (area of vacuum around the lungs) the air will take that shortcut in preference to the long route through your nose, down the pharynx, down the trachea and into the lungs. So, mechanically, if there is a hole in the chest wall, it needs to be covered up with something that is airtight. In a simple vacuum system, this will restore the pressure difference, and allow the breathing to return to normal. Unfortunately, people are not always quite that simple.

Complication #1: sometimes there is a hole in the lung. So, sometimes when there is a hole in the lung as well as the chest wall (or, absent a hole in the chest wall. I'll get to that in a bit.), a little bit of air will spill out into the chest cavity with each breath. When that starts happening, those little bits of air start building up, and causing the pressure in the space to be equal or greater than the space outside. If that happens, the lungs will once again not be able to expand. If that happens, the treatments are relatively easy. First, try to release some of the air that is building up, by lifting part of the chest seal for just a moment, while the patient is exhaling. Burp the seal, then get it sealed back up. Hopefully, that will buy your patient time. Failing that, it's time to start thinking about doing a needle decompression, which is an entire thread in itself, and not something I am sure I would try to teach via internet.

Complication #2: lung holes WITHOUT exterior holes. Let's say that you are a really tall, skinny guy who does lots of running. For some reason, one day you are out running/playing basketball/athletic thing of your choice, and you can't seem to catch your breathe when you are done. It's not an asthma attack. But as time goes on, you are having a harder and harder time catching your breathe.....There is a chance you have developed a spontaneous pneumothorax. A small hole has been torn in one of your lungs, and air is (as above) spilling into your thoracic cavity and causing difficult breathing. Unfortunately, unlike the standard pneumo listed above, this injury can't be burped. All you can do to help this patient is the needle decompression. This closed style of pnuemothorax can also be caused by blunt trauma to the chest, via either a paper bag injury or broken rib segments. So, keep it in mind.

Complication #3: Blood. For some reason, people who get holes in their chest have a tendency to leak fluids as well as have air coming out of spots it's not supposed to. Inconsiderate jerk faces! Not only does this mean less blood circulating in the system, it also means that some of that blood might be building up inside the pleural space, and liquid is an even bigger issue for pressures than air, due to it's incompressible nature. The only thing that will help with this is chest tubes, and that is a procedure I sure as hell am not going to try to teach over the internet. If you suspect fluid is building up in the patients chest, and that is causing the shortness of breath, it's time to drive faster to your higher level of medical care.

Now with those issues out of the way, back to the actual question, what is best way to treat the sucking chest wound? Is it
A. A four sided occlusive dressing like a Halo.
B. A self-burping seal like a Hyfin, Bolin, or Asherman.
C.A three sided dressing, like part of an MRE package duct taped down on three sides.
D. All of the Above.
Or is it
E. Throwback doesn't give a damn so long as the intervention makes sense and works? If you answered E, you are on the right track. If I take a round, and am gasping for air because of the hole in my chest, I don't care if you attach the latest and greatest medical device to my body, or if you cover the hole with a couple strips of duck tape. I suppose if I were to express a preference, I would prefer a four sided occlusive, and good patient monitoring. But I will take anything over having a big open hole in my chest, and we can discuss the finer details of improving the intervention AFTER something has been done to start fixing the issue. Speed and understanding of principle is more important than specific gear on this one.

Signs and symptoms that warrant a chest seal-type intervention for the first responded:
Any hole from neck to navel. Period. If they have a hole, cover the hole. I would rather loose some of the extra hair from my year around sweater than I would spend even a minute struggling to breath from a hole.

This ends all the stuff on chest seals I NEED my guys to know. All the rest is more good to know than required......


Things that tell you that a tension pneumo is developing, and you need to consider burping the seal or a decompression: Mechanism of injury that supports potential Pneumo and difficulty breathing.
For the lay responded, that is about it. What I generally tell my guys is that if I am damaged enough to not fight them on the needle stick, I am bad enough that the stick isn't going to hurt anything. If I am healthy enough to tell them to try burping the seal first, they better try that before shoving a needle in my chest. But if you want to see a more complete list of signs and symptoms of a pneumo, and how bad a sign it is.....
Difficulty breathing: Common, and the first thing to start making you worry.
Obvious use of accessory muscles: a sign that the difficulty is bad enough that the patient is really struggling.
Diminished lung sounds via stethoscope: A solid indication that the side you are listening to is no longer inflating, and therefore needs to be treated, post haste.
Unilateral rise and fall of the chest: if only one side of the chest seems to be moving, this usually indicates that the non-working side no longer has a pressure differential to work with. Bad sign.
Hyper/hypo resonance on the affected side: the side of the chest that is having the issue might sound different when you tap it. Think of the sound a drum makes vs. a “normal” chest sound. If the side sounds full, that might be blood in there, and that is a very bad thing.
Subcutaneous emphysema: when you press on the skin of the affected side, does it make rice crispy sounds? Does it remind you of popping bubble wrap? These are signs that air is leaking, and getting into the tissues under the skin. This indicates lots of air leaking into areas of the thorax that it shouldn't be.
Jugular vein distension: If the veins of the neck are starting to stick out, it indicates that patient has such high pressure in the chest that the heart is no longer able to fully expand, leading to a back up of blood towards the brain. This patient needs an intervention RIGHT NOW.
Tracheal deviation: if the trachea is no longer in the center of the neck, and has started to pull in one direction or the other, this indicates that they patients other lung is no longer working. The pressure is so great that it is shifting organs away from the high pressure side and towards the functional side. This is another very bad sign that indicates that the patient needs and intervention RIGHT NOW.

One last parting thought: If the patient is conscious, let them pick a position of comfort to be transported in. If I am all messed up from a chest wall injury, I don't want you telling me to lay on my back like I am having an Xray taken. Good luck, and hopefully, you will never need this data.

Re: Treatment for "sucking chest wound"

Posted: Sun Nov 09, 2014 8:02 pm
by DannusMaximus
throwback wrote:Complication #2: lung holes WITHOUT exterior holes. Let's say that you are a really tall, skinny guy who does lots of running. For some reason, one day you are out running/playing basketball/athletic thing of your choice, and you can't seem to catch your breathe when you are done. It's not an asthma attack. But as time goes on, you are having a harder and harder time catching your breathe.....There is a chance you have developed a spontaneous pneumothorax.
The guy in my ER was indeed a tall, skinny dude, and when I was talking with some of the more veteran nurses and techs afterwards, the consensus was that tall and skinny = a greater chance of developing a spontaneous pneumothorax. Not sure exactly why that predisposes you, but there it is. Luckily I'm tall and blocky... 8-)

Nice post, btw, throwback.

Re: Treatment for "sucking chest wound"

Posted: Sun Nov 09, 2014 8:39 pm
by IANMCDEVITT
Kind of oversimplified guys. I should say way over simplified. The first SIGNS of a tension should be penetrating chest injury, patient wont lie flat or inability to complete full sentences.
...by fhe way. That "tall guy thing" is Marfans, wiish had more time but dutch are waiting and have to cause some tensions myself.

Re: Treatment for "sucking chest wound"

Posted: Mon Nov 10, 2014 8:56 pm
by Bubba Enfield
IANMCDEVITT wrote:Kind of oversimplified guys. I should say way over simplified. The first SIGNS of a tension should be penetrating chest injury, patient wont lie flat or inability to complete full sentences.
I enjoyed reading Throwback's simplification. I also appreciate Ian's input.

Re: Treatment for "sucking chest wound"

Posted: Mon Nov 10, 2014 9:20 pm
by IANMCDEVITT
Thanks. Helicopters are a distant dream. We go by ground. No one, NO ONE LIES FLAT unless they are expectant. Its so much diffrent thank you think and everything read is a fallacy on the the net that is.... that, and a ZSU -23 2 IS THE DEVILS OWN CREATION.

Re: Treatment for "sucking chest wound"

Posted: Wed Nov 12, 2014 1:13 am
by acropolis5
Throwback, Thanx. I'll have to re-read it to gain a fuller understanding, but I got the part about close up the hole with an airtight dressing.

Re: Treatment for "sucking chest wound"

Posted: Mon Nov 17, 2014 12:29 pm
by DrJack
To echo what Ian said, most of the Pnuemothorax pts I have seen have been in sever respiratory distress, gasping for air, etc. Another key note is that the respiratory distress is PROGRESSIVE, that is to say, each breath is harder to take than the last.

Also as mentiond above, it doesn't really matter which device you use as long as it works and you know what you are doing with it. I've also mentioned here several times that the adhesive on Asherman chest seals works about as well as nailing water to a tree.

Hyfin and Halo are my preference by a LONG way simply because there are the stickiest and I've seen work on patents covered in blood, sweat, and tears.

As far as CLS classes teaching decompressions, it is because there are in a much higher likelyhood of seeing a tension pneumothorax and are trained specifically for it among a few other very likely but very treatable injuries. (In my experience the average CLS person gets more caught up in treating injuries than treating symptoms, but that comes more from CLS classes being taught by medics who have very little medical training....)

Anyhow, I'm rambling. Treat what you're taught to treat how you're taught to treat it. Monitor your patient, and give them what they need to keep air going in an out and blood to go round and round.

Re: Treatment for "sucking chest wound"

Posted: Mon Dec 01, 2014 4:39 pm
by BullOnParade
Great thread guys, I love the input (even if especially since it's simplified). I'm in the process of putting together supplies for my club FAK, and restocking my own. Because the club kit is going to be available for everyone in the club, and I don't think (m)any of the club members have ever considered the idea of treating a sucking chest wound, I'm going with vented seals.