What is the proper sequence of steps in managing a patient with an open pneumothorax secondary to a gunshot injury?

Management of Open Pneumothorax from Gunshot Injury

The proper sequence of steps for managing an open pneumothorax secondary to a gunshot injury begins with immediate activation of the emergency response system, followed by application of a vented chest seal or non-occlusive dressing, and then close monitoring for signs of tension pneumothorax. 1

Initial Management

• An open pneumothorax from a gunshot wound is a medical emergency requiring immediate activation of the emergency response system 1
• First, temporarily cover the wound with a gloved hand to prevent further air entry while preparing proper materials 2
• Apply a clean, non-occlusive dressing (e.g., gauze dressing) or a specialized vented chest seal over the wound 1
• The dressing should be secured on three sides only, leaving one side open to act as a one-way valve that allows air to escape during exhalation but prevents entry during inspiration 2

Rationale for Non-Occlusive Dressing

• The goal is to prevent air entry through the wound while still allowing air to exit the pleural space 1
• A fully occlusive dressing can lead to fatal tension pneumothorax by preventing air from exiting through the chest wound 1
• The greatest concern is improper use of an occlusive dressing that could lead to tension pneumothorax 1

Monitoring After Dressing Application

• Continuously monitor the patient for signs of worsening breathing or developing tension pneumothorax 1
• Signs of tension pneumothorax include: diminished or absent breath sounds, severe dyspnea, narrowing pulse pressure, tachycardia, restlessness, and eventually tracheal deviation toward the unaffected side 2
• If breathing worsens after dressing application, immediately loosen or remove the dressing 1

Definitive Management

• After initial stabilization, tube thoracostomy (chest tube placement) is the definitive treatment for traumatic pneumothorax 3
• For large open pneumothoraces, current guidelines recommend tube thoracostomy rather than conservative management 4
• A moderate-sized chest tube (16F to 22F) is appropriate for most patients 1
• For unstable patients or those at risk for large air leaks (requiring mechanical ventilation), a larger chest tube (24F to 28F) may be necessary 1

Chest Tube Management

• Connect the chest tube to either:
  • A water seal device with or without suction 1
  • A Heimlich valve (one-way valve) 1
• If the lung fails to re-expand with water seal drainage alone, apply suction 1
• Monitor for proper chest tube function and resolution of the pneumothorax 1

Surgical Considerations

• Thoracotomy may be required in cases with:
  • Significant ongoing bleeding
  • Large air leak that doesn't resolve
  • Extensive lung parenchymal damage 5
• Only 6% of civilian thoracic penetrating injuries require operative repair of pulmonary hilar or parenchymal injury 5
• Pulmonary resection is rarely necessary (only about 1.5% of cases) 5

Common Pitfalls and Caveats

• Failing to recognize development of tension pneumothorax after dressing application 1
• Using a fully occlusive dressing without a mechanism for air to escape 1
• Inadequate monitoring after initial management 1
• Performing needle decompression without first ensuring proper placement and function of the chest seal 2
• Delaying definitive management with tube thoracostomy in unstable patients 1

Remember that the primary goal in managing an open pneumothorax is to prevent air entry while allowing air to exit, followed by definitive management with tube thoracostomy and close monitoring for complications.