Emergency Medical Care—Open Chest Wound

The open chest wound is an immediately life-threatening emergency that can lead to rapid
deterioration and death if not managed properly. Emergency medical care includes the general
care we have just detailed, plus the following:
1. Immediately seal the open wound with your gloved hand.
Do not delay in order to find a dressing.
2. Apply an occlusive dressing to seal the wound
(not a regular porous dressing, which would allow air to enter easily). Plastic wrap from an
oxygen mask, the wrap covering an intravenous fluid bag, or Vaseline gauze may be used. The
occlusive dressing should be a few inches wider than the wound. Place it over the entire wound
and tape it on three sides (Figure 34-18 ■). During inhalation, the dressing is sucked up against
the wound, preventing air from entering. The side that is not taped allows for air that has built up
in the thoracic cavity to escape during exhalation (Figure 34-19 ■). An alternative method is
to tape the dressing on four sides and occasionally lift a corner during expiration to relieve any
pressure. Paramedics and some Advanced EMTs are able to decompress the chest to relieve the
trapped air using an over-the-catheter needle. A valve may be connected to prevent air from
being drawn into the catheter. The Asherman Chest Seal (ACS) is a commercially available self-
adhesive translucent occlusive dressing that covers the open chest wound and has a built-in one-
way flutter valve to allow air to be relieved during exhalation (Figure 34-20 ■).
3. Continuously assess the patient’s respiratory
status.
If the patient’s condition begins to deteriorate and you notice more severe signs and symptoms of
respiratory distress along with signs of shock, a tension pneumothorax may be developing. The
occlusive dressing, even if taped on only three sides, may have become obstructed by trauma or
clotted blood, preventing air from exiting the open wound in the chest, or air may be entering the
thoracic cavity from a hole in the lung. The following signs and symptoms indicate a
complication associated with the sealed wound and a developing tension pneumothorax. Thefirst
three are the most important to recognize:
 Difficulty breathing, with increased respiratory distress and dyspnea (shortness of breath)
 Tachypnea (breathing rate faster than normal)
 Severely decreased or absent breath sounds on the injured side
 Cyanosis
 Tachycardia (heart rate faster than normal)
 Decreasing blood pressure with a narrowing pulse pressure
 Jugular vein distention (late sign)
 Tracheal deviation (late sign)
 Unequal movement of the chest wall (the injured side remains hyperinflated and will not
move equally with the uninjured side)
 Extreme anxiety and apprehension
 Increased resistance to positive pressure ventilation
 If these signs and symptoms develop after the occlusive dressing has been
applied, you must lift a corner of the dressing for a few seconds to allow the air to escape
during expiration. A rush of air may be heard or felt, and immediate relief of the signs
and symptoms of severe compromise should occur. Reseal the wound with the occlusive
dressing. It may be necessary to repeat this procedure sever
al times

Treatment for Tension Pneumothorax

A needle decompression is a medical procedure that is most commonly used to treat patients
suffering from a tension pneumothorax. A tension pneumothorax occurs when air pressure
builds up in the space between the inner and outer membranes that surround each lung, an area
known as the pleural space.

A military medical worker uses needle decompression to treat a

person with a tension pneumothorax.

A tension pneumothorax is usually the result of an object puncturing a person's lung (such as
when a stick punctured the lung of Kim's patient). When an object punctures a lung, air may
leave the lung and get trapped in the pleural space. As more air fills the pleural space, the
pressure builds up and can potentially lead to a collapsed lung.
Additionally, the increased pressure may block blood flow to the heart. If blood flow to the heart
is blocked, the heart will not be able to pump blood throughout the body, which can lead to a
quick death. A needle decompression involves inserting a needle into the pleural space to remove
this excess air and pressure.

Technique
When performing a needle decompression, nurses and other healthcare professionals should
perform the following steps:

1. On the rib cage surrounding the injured lung, find the second intercostal space (space
between the second and third ribs) at the midclavicular line (imaginary vertical line in the
body at the middle of the clavicle).
2. Clean this area with an iodine solution (such as Betadine).
3. Insert a large needle (14 gauge or larger) attached to a catheter into the spot where the
midclavicular line crosses the second intercostal space. The needle will need to be about
5-8 cm long, depending on the amount of muscle and fat tissue covering the rib cage. The
needle should be inserted at an angle that is perpendicular to the chest. Go over the top of
the rib as there are veins, arteries, and nerves that run beneath the ribs.
4. Insert the needle until a hissing sound is heard. This hissing sound is the sound of air
leaving the pleural space.
5. Remove the needle, making sure that the catheter stays in place.
6. Ensure the catheter is secured to the patient's body.

To perform needle decompression, the needle should be

inserted in the second intercostal space at the midclavicular
line.
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