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Lesson

Open Chest Wounds & Seals

10 min Trauma Skip to quiz

Objective: If the patient is breathing on their own, a vented chest seal is reasonable. If you are ventilating with a bag-valve mask, or the patient is intubated, do not seal the wound by default. Watch for tension. Do not pack the chest, and do not use a three-sided flutter dressing.

Why this matters

An open chest wound can pull air in when the patient breathes on their own. First, decide whether the patient is breathing without your help. If they are, a vented chest seal is reasonable. Check for tension after you apply it. Do not seal every chest wound by habit.

If you are ventilating with a bag-valve mask, or the patient has a tube and you are using positive-pressure ventilation, a seal can trap air and create a tension pneumothorax. A tension pneumothorax is air under pressure that causes obstructive shock. Chest seals are not the default in that group. A three-sided flutter dressing is no longer recommended. Do not pack the chest the way you pack a groin.

Key points
  • Wipe blood and sweat off the skin so the seal sticks. A seal placed on wet skin will not stay on.
  • Look at the back. Penetrating chest trauma can have a second wound you did not dress.
  • If the patient gets worse after a seal, lift one edge, remove the dressing, or decompress per protocol. Lifting one edge is sometimes called burping the seal.
Verbalize
  • The patient is breathing on their own. I will use a vented seal if we have one.
  • We are ventilating with a bag-valve mask, or the patient is intubated. I will not seal the wound by default.
  • I will not pack an open chest wound the way I pack a groin.
  • The patient is worse after the seal. I will lift one edge, remove it, or decompress.
Package of a vented chest seal made for an open chest wound.
The package is one example of a vented chest seal. If the patient is breathing without your help, wipe the skin and apply a vented chest seal if you have one. Look at the back for a second wound. If you are using a bag-valve mask, or the patient has a tube, leave the wound open and watch it. Positive pressure plus a seal can trap air. If the patient gets worse, lift one edge, remove the dressing, or decompress per protocol. Do not use a three-sided flutter dressing, and do not pack the chest. A needle is for tension, not for a simple leak. Photograph by Bump2a, Wikimedia Commons, CC BY 4.0. Cropped and contrast adjusted. The package is an example. Protocol decides when a seal is appropriate.

Clinical sequence

  1. MARCH still applies: massive hemorrhage, airway, respirations, circulation, then hypothermia and head injury. Stop massive external bleeding first if it is spurting. Then manage the airway. Then manage the chest wound.
  2. If the patient is breathing on their own, wipe the skin and apply a vented chest seal if you have one. Use an unvented seal only if that is all you have, and then watch closely for tension.
  3. If the patient is on a bag-valve mask or has a tube, do not apply an occlusive seal as the default. Positive pressure already pushes air in. Occlusion can cause tension. Watch the wound.
  4. If the patient gets worse, lift one edge of the dressing, remove it, or decompress per protocol. Roll the patient and look at the back for a second wound.
  5. If an object is still in the chest and it is not blocking the airway, stabilize it in place. Do not pull it unless it blocks the airway and you are trained and authorized to remove it.

Key points

  • This is not wound packing. Gauze in the chest is not the treatment for a junctional bleed, and it is not the treatment for an open chest wound.
  • Both sides of the chest can be injured. Look at the back.
  • Positive-pressure ventilation can turn a simple pneumothorax into tension. A simple pneumothorax is air in the chest without obstructive shock. Reassess after you start ventilation or after you intubate. Do not add a seal that blocks air from leaving.
  • Three-sided dressings are no longer recommended. Use a vented seal if the patient is breathing on their own. If you are using positive pressure, watch an open wound instead of sealing it by default.

Common errors

  • Taping all four sides with no vent and no reassessment.
  • Sealing a ventilated or intubated chest so it is airtight, then walking away.
  • Missing the exit wound.
  • Spending a long time on a perfect dressing while a patient with a torso wound is deteriorating.

Practice

One-minute check

On a trainer, apply a vented seal in under 30 seconds. Wipe the skin so the seal sticks. Then the patient gets worse. Say whether you lift one edge, remove the seal, or decompress, and check the back for a second wound.

Related: Tension pneumothorax.

Sources & Further Study

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

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. Sucking chest wound, they are breathing on their own; hemostatic gauze is in your hand. Best move is:
2. You sealed it; two minutes later they are harder to bag and more hypotensive. You must:
3. Knife still in the chest wall, not blocking the airway. Field teaching is:
4. Anterior seal looks perfect. Why roll/look at the back?
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