This Sucks!

Let’s talk about a condition typically known as an open pneumothorax or more commonly, the "sucking chest wound".

What is it? The 'sucking' comes from the sound the wound makes as air is drawn in and out of the thorax. The chest/thorax is essentially a closed system with the trachea being the only opening. Respirations are affected by the diaphragm contracting and flattening out which expands the chest and creates negative pressure in the chest cavity and draws air into the lungs, thereby equalizing pressure. Think of it kind of like a bellows used to fire a forge. As the pressure is equalized, oxygen and waste are exchanged, oxygen goes into the blood to be distributed throughout the body and the waste is expelled in the form of carbon dioxide during exhalation.

How do I recognize it? Basically, the sucking chest wound is a simple, open pneumothorax, which is when the thorax is penetrated by shrapnel, bullets or other penetrating trauma (in this case) and air is allowed into the chest cavity through the hole, thereby collapsing the lung. What are the symptoms? Obvious injury to the thorax (entrance/exit wounds) with difficulty breathing (rapid, shallow breathing), 'sucking sound' with pinkish-bloody frothy bubbles coming out of wound, unequal rise and fall of the chest, absence of movement on the affected side or decreased or absent breath sounds on the affected side (for those who carry and use a stethoscope). The thorax is very vascular and even if the wounds don’t bleed much externally, they will still bleed quite a bit internally and we can’t see the extent of the internal damage.

How do I treat it? This is an immediate treatment injury. An occlusive dressing needs to be applied and the casualty needs to be monitored for the development of a tension pneumothorax--which we'll get to shortly. We utilize the HALO Seal or HALO Vent Seal occlusive dressing in our Direct Action Response Kit (D.A.R.K.) as it sticks very well and they come as a pair (the Vent has one vented and one non-vented seal). An occlusive dressing can be anything airtight which covers a border of 2" outside the wound. You may not always have HALO Seals on hand, so anything that can be airtight needs to be applied, yes, even duct tape and a plastic wrapper will suffice. In this instance, thinking outside of the box is critical. Control any life threatening hemorrhage, evaluate the airway, have the casualty exhale, apply the dressing over the wound and secure it in place. Now, something extremely important to remember is to check for any exit wounds as well as they will need to be dressed as well. You can utilize hemostatic gauze superficially but DO NOT pack gauze into the thoracic cavity. Basically, anything from the bellybutton to the collarbone on all four sides is off-limits to packing (unless it’s a non-penetrating injury like a large cut) and will benefit from an occlusive dressing. That’s our “box”. We seal the box and TQ/pack the limbs.

There have been some back and forth changes concerning 3 or four sided dressings. Current data from the Committee on Tactical Combat Casualty Care guidelines call for a ‘vented’ seal first and a ‘non-vented’ seal if the ‘vented’ isn’t available. We teach both dressings as you will be monitoring the casualty for any signs and symptoms of a developing tension pneumo as well. This is because the ‘vented’ seal can become clogged with blood, dirt and debris and form an entirely occlusive dressing or the wound itself can occlude the pathway of air. This is why we watch the patient, not just the intervention. Positioning of the patient has been questioned (affected side down/affected side up) and based on feedback from providers in the field, we advocate affected side down as the injury will involve hemorrhaging as well and it is best to leave it in a dependent position so as not to impede oxygenation with the unaffected side. Also, it can be the provider's call in the field to position the casualty in the position which increases both comfort and ability to oxygenate easier. Recovery position works well and it aids in maintaining a patent airway but if the victim is conscious let them breathe in whatever position is most comfortable for them.

As the casualty is monitored, observe for any increased difficulty in breathing, increased rate of breathing, bluish tinge around the lips or skin, anxiety, altered mental status, jugular venous distention or in the worst-case scenario, the trachea is actually deviated (pushed away) from midline. The victim's heart rate will be extremely elevated as well as the respiratory rate. If the chest wall is percussed over the affected side, it will have ‘hyper-resonance’ and sound somewhat like a tympani drum. This is a tension pneumothorax and it will prove fatal unless rapidly treated. This can be very insidious and take some time to occur, sometimes up to 2 hours. Even if the casualty has a properly placed occlusive dressing on the wounds, air can still enter the thorax via the trachea and the injured lung, thereby increasing pressure in the thorax until it pushes the heart and great vessels over to the uninjured side. This can compress them and the uninjured lung, compromising both the ability to oxygenate and pump blood and will lead to death.

How is the tension pneumo treated? If the wound can ‘vent’ itself through the passive “Vent” in a vented seal, that’ll work. If you have a completely occlusive dressing, you can "Burp" it by lifting up on the edge of the dressing. There may be a 'rush' of air and possibly blood as it leaves the pleural space and they will have almost immediate relief and breathe easier. Another method, advanced practice only—not for the layperson, is the needle decompression in which a 14 gauge or larger needle is inserted into the thorax at a specific landmark and releases the air buildup. The disadvantage to this is that the smaller gauge catheters can collapse or plug and the casualty may require multiple decompressions. A word of caution, even if you’ve been trained to do this procedure in the military or in a class, unless you are an advanced practice provider (PA, MD, NP) or acting under direct medical control, you cannot legally perform this procedure.

The most effective way to relieve and treat this is with a chest tube placement, which would typically be done in a Forward Surgical area by a Physician or PA or in the field (worst case scenario) by the medic, if trained, in order for the lung to re-expand and surgery to be performed to treat and alleviate any other injuries. Sucking chest wounds suck, literally and figuratively, but with rapid, efficient treatment, you can buy the casualty some valuable time, keep them in the fight and ultimately save their life.

Stop the bleeding, start the breathing.
Seal the front, check the back.