Need some information Re: Chest Wounds

[davidjinks]

I just went through my recert for emergency first responder training.

When going over wound care/stop the bleed, the topic of sucking chest wounds came up. The directive we were given was to control bleeding and NOT seal the chest wound. The idea is that we control the bleed and that there will be enough time for EMS to get there before we start being concerned with tension pneumothorax.

I disagreed with that and stated I would go into bleed control and then sealing the chest wound if it was indeed a sucking chest wound.

Can anyone add any their thoughts on this?

Is it good to just control the bleed, stabilize and wait or get to it and seal the wound if needed?

[1168]

When you get to the B in H-ABC, the most clinically appropriate thing to do would be to seal it. At least get a gloved hand over it. Continue checking for other wounds.

I do not prefer to arrive at a shooting and five people with gloves on are staring at an open hole in the chest.

Its important to note that I did not write your local protocols, so act appropriately in accordance with your organization’s policies.

[Hmac]

When you get to the B in H-ABC, the most clinically appropriate thing to do would be to seal it. At least get a gloved hand over it. Continue checking for other wounds.

I do not prefer to arrive at a shooting and five people with gloves on are staring at an open hole in the chest.

Whereas I think the clinically appropriate thing to would be to assess the patient and determine whether or not the wound is clinically relevant. The wound isn't the problem. The physiological effect of the wound is the problem. Is the patient ventilating? Oxygenating? Is there JVD? Tracheal deviation? BP? Heart rate? Those things all go into the decision matrix as to how that wound is managed in the field and are more important than the mere fact that there is a chest wound.

[Leftie]

Whereas I think the clinically appropriate thing to would be to assess the patient and determine whether or not the wound is clinically relevant. The wound isn't the problem. The physiological effect of the wound is the problem. Is the patient ventilating? Oxygenating? Is there JVD? Tracheal deviation? BP? Heart rate? Those things all go into the decision matrix as to how that wound is managed in the field and are more important than the mere fact that there is a chest wound.

This is where "protocol" and context become difficult to navigate, and there isn't a definitive answer. Those of us with some experience in the medical community (either in EMS/prehospital settings or in definitive care settings), no matter what level of experience or expertise have all probably fallen into the paradox of "well if I choose this intervention based upon what signs/symptoms I am seeing, it might deviate from a textbook protocol... BUT IT WILL PROVIDE A BETTER PATIENT OUTCOME and greater chance of survivability." This calculus is nearly entirely based on a sound assessment of a real patient and the hierarchies found within provision of care based upon what you are observing.

I would say that a good bet is to follow local/your agency's SOPs, and follow whichever acronym they have adopted, but recognize that others exist and that there are nuances between them. MARCH, H-ABC, SCAB-E, CAB etc... they all have nearly identical priority hierarchies, and controlling hemorrhage falls above nearly everything else... in context. On the other hand, once you've fixed the massive bleed, I don't see anything wrong with properly applying a chest seal per SOP and monitoring the patient for signs of respiratory difficulty and tension pneumothorax, and then "burping" the seal as needed, but really, it's contextual to the extent of trying to figure out what will kill the patient first and fastest, and then solving for said problem. It's really hard to mess up a chest seal if you are continuously monitoring your patient's status and understand how the intervention works.

Even then... I've seen laypeople taught how to properly apply chest seals by my jurisdiction's medical director, and while the signs and symptoms of tension pneumothorax were discussed and taught to them, in the context of where this training is being held (an area where a Level I trauma center is no more than 15 minutes away at any time) he isn't concerned about tension pneumos.

For reference, my experience is at the prehospital level, so your mileage may vary with the above.

[just a scout]

Agreed. It’s pretty easy to slap a piece of something on the to seal it. Don’t have to worry about chest farts or anything at your level but if protocols allow, plastic or a Vaseline gauze or best yet a real chest seal can save a life.


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[ST911]

When going over wound care/stop the bleed, the topic of sucking chest wounds came up. The directive we were given was to control bleeding and NOT seal the chest wound. The idea is that we control the bleed and that there will be enough time for EMS to get there before we start being concerned with tension pneumothorax.

What your instructor likely meant was that a tension pneumo is a later threat, and may not occur within your local EMS response time. If that's the case, they were right.

Once priorities were handled, I would apply a manufactured or improvised chest seal. Note that chest seals aren't a topic in the STB curriculum.

This is a topic many classes can get bogged down on. "Chest" seals vs the circumference of the thorax between the landmarks, vented or not, manufactured or improvised. For many students, time is better spent on learning on bleeding control, maintaining an open airway, recovery position. When I teach it to a lay class, I explain to put the body back like it was (sealed) with whatever they've got, and fart when you need to.

[Hmac]

Good lord, the mystery of "sucking chest wounds".

Do yourself (and your patient) a favor...don't overthink. You can address the "sucking chest wound" after you're sure that you've addressed all of the potentially more urgent problems. Mishandling a "sucking chest wound" is likely to do more harm than good.

[LMT Shooter]

Good lord, the mystery of "sucking chest wounds".

Do yourself (and your patient) a favor...don't overthink. You can address the "sucking chest wound" after you're sure that you've addressed all of the potentially more urgent problems. Mishandling a "sucking chest wound" is likely to do more harm than good.

Will you please elaborate in detail as to the specific things that you refer to as "mishandling?"

[Hmac]

Will you please elaborate in detail as to the specific things that you refer to as "mishandling?"

Automatically slapping some kind of occlusive dressing, maybe with some kind of overly-elaborate valve mechanism, without having an understanding of respiratory physiology, the physiology of pneumothorax, nor chest anatomy. So focused on the one wound that other more important injuries are mis-prioritized or missed altogether.

[LMT Shooter]

Automatically slapping some kind of occlusive dressing, maybe with some kind of overly-elaborate valve mechanism, without having an understanding of respiratory physiology, the physiology of pneumothorax, nor chest anatomy. So focused on the one wound that other more important injuries are mis-prioritized or missed altogether.

Gotcha, thanks.