A special thank you to Myles Francis of Archangel Dynamics for allowing me to publish his Tactical Medicine posts here on Vigilant Wolf. Myles is a friend and past guest of Ever Vigilant podcast (episode 59).
As always, this post is provided for educational / information purposes only. Follow your local protocols, we are not responsible for what you choose to do with this information.
From the name we can gather that penetrating chest trauma describes a traumatic injury caused by penetration of the chest wall. These injuries are frequently seen in a tactical setting, but can occur anywhere. Common mechanisms of injury are gunshot, stab and shrapnel wounds. If not promptly and aggressively managed, these injuries have the potential to develop a Tension Pneumothorax (Tension Pneumothorax), an immediately life threatening condition that will result in traumatic arrest if not addressed. See last week's post for more information on Tension Pneumothorax.
Once the chest wall is breached, air follows the path of least resistance and rushes into the newly formed defect, trapping itself between the lung and chest wall. Gurgling sounds can be appreciated, as can bubbling blood, which is where the name “sucking chest wound” comes from. The goal behind treatment of penetrating chest trauma is to prevent more air from entering the chest cavity from the wound, and to prevent or treat any tension pneumothorax that occurs by releasing trapped air. For large injuries, more than one chest seal may be needed, or one may need to be improvised if commercial seals are not large enough to cover the defect. It is a good idea to have a large sheet of Hydrogel in your aid bag that can be cut to size as needed.
When covering a defect, the general consensus is to use a vented seal, to allow air and/or blood to escape from the chest cavity. A non vented seal can certainly be used, but this is not ideal. However, like any intervention provided, frequent reassessment of the patient is critical, especially with a Tension Pneumothorax. It is also worth noting that bullets often deviate inside of a body cavity. Current TCCC guidelines recommend placing an occlusive dressing over any penetrating injury between the groin and the clavicles in case a bullet penetrates the diaphragm.
Never attempt to remove an impaled object, stabilize it in place. It is important to remember that management of a patient with a penetrating chest injury is not a one and done deal. Simply slapping a seal on is not sufficient. Patients can rapidly deteriorate. Patients who have had a chest seal placed need to be closely watched and evaluated until a chest tube can be placed, and even then, still require frequent monitoring. When working in the ER, I will often tape a decompression needle to the chest of any patient who receives a chest seal, as a visual reminder to everyone in the resuscitation bay. On the helicopter, I carry several NAR ARS Needles in my flight suit, allowing for rapid decompression if needed.
1. Locate the site of injury.
2. Apply the vented chest seal (or occlusive dressing) over the wound upon EXHALATION.
3. It is very common to find an exit wound, or “pass through injury” with trauma to the torso. Roll the patient and expose the back of the body. If a second wound site is found, apply a second vented chest seal (or occlusive dressing) over the wound, again, on EXHALATION. Place a seal on any penetrating injury between the clavicles and the groin
4. If there is no contraindication (such as a possible spinal injury), allow the patient to sit up, this will help relieve anxiety and help the patient breathe more easily.
5. Continuously reassess your patient. Look for signs of Tension Pneumothorax. If noted, lift the seal and allow air to escape from the chest. If any clots are present, gently brush them aside to facilitate air release from the chest.
6. If this does not relieve Tension Pneumothorax, decompress the chest immediately. Follow your local protocols. Start by using a chest decompression needle. If this does not alleviate symptoms, progress to a Finger or Tube Thoracotomy.
7. For the critical care providers reading this, any tension pneumothorax that is intubated and placed on a ventilator should have a chest tube placed.
8. Frequently reassess the patient. Even if tension is relieved, a patient can easily re-tension.
9. If you haven’t done so already, transport the patient to definitive care.
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