Open Chest Wounds & Seals

Why This Is Hard

A hole in the chest wall lets air in on inspiration and can build a tension pneumothorax if you tape it airtight on all four sides and walk away. TCCC/TECC teaching prefers a vented chest seal. If a vented seal is not available, use a non-vented occlusive seal and watch closely. The old three-sided “flutter valve” dressing is a fallback teaching idea, not co-equal with a commercial vented seal. You must reassess for tension and be ready to burp or remove the dressing, or decompress per protocol.

Street Sequence

1. MARCH still applies. Massive external bleed first if it is pumping. Then airway. Then this hole.
2. Expose, wipe blood so the seal sticks, apply a vented chest seal when you have one. If not, a non-vented occlusive seal is the TCCC fallback — then reassess.
3. High-flow O₂ as indicated. Sit up if they tolerate it and spine rules allow.
4. Watch: increasing distress, unilateral findings, hard bagging, hypotension — treat as tension (tension lesson).
5. Impaled objects: stabilize, do not pull in the field unless it is blocking the airway and you are trained/authorized.

Key Points

• This is not wound packing. Gauze stuffed into the thorax is not junctional hemorrhage care.
• Both sides of the chest can be injured. Look at the back.
• Positive-pressure ventilation can convert a simple pneumo to tension — reassess after intubation.

Field Pitfalls

• Four-sided tape, no vent, no reassessment.
• Missing the exit wound.
• Prolonged scene time for a perfect dressing on a crashing torso-shot patient.

Practice

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• TCCC guidelines (Committee on TCCC)
• ATLS / ACS trauma education
• TCCC: vented chest seal preferred; non-vented if that is what you have; monitor for tension and burp/decompress if it develops. Do not pack the thoracic cavity like a junctional bleed.