Which types of chest injuries require placement of a chest seal?

Chest Seal Indications for Penetrating Thoracic Trauma

Chest seals are indicated for open chest wounds that penetrate through the chest wall into the pleural cavity, particularly large defects from high-velocity rifle wounds, shotgun wounds, and blast injuries that create significant air communication between the external environment and pleural space. 1

Specific Injury Patterns Requiring Chest Seals

Large Chest Wall Defects (Primary Indication)

• High-velocity rifle wounds, shotgun wounds, and blast injuries create large chest wall defects that allow significant air entry during inspiration, making them the primary candidates for chest seal application. 1
• These injuries create sufficient airflow resistance through the chest wall defect to impair normal ventilation through the trachea 1

Small Penetrating Wounds (Generally Do NOT Require Seals)

• Stab wounds, most handgun wounds, and many rifle wounds create small defects that typically do not generate enough air leak to impair respirations 1
• These smaller wounds generally do not benefit from chest seal application 1

Massive Blunt Trauma

• Open chest wounds from massive blunt chest trauma that create communication between the external environment and pleural space are medical emergencies requiring consideration of chest seal placement 1

Critical Management Algorithm

Initial Assessment

• Any open chest wound is a medical emergency requiring immediate activation of emergency response systems. 1
• The wound must penetrate through the chest wall into the lung cavity to warrant chest seal consideration 1

Treatment Options (In Order of Preference)

The 2024 American Heart Association guidelines provide three reasonable options: 1

1. Leave the wound exposed to ambient air (acceptable first-line approach)
2. Apply a clean, nonocclusive, dry dressing (e.g., gauze, part of a tee shirt)
3. Apply a vented chest seal (specialized dressing)

Vented vs. Unvented Seals

• If using a commercial chest seal, vented seals are superior to unvented seals because they prevent tension pneumothorax development while still reducing air entry. 2, 3
• Unvented seals led to tension pneumothorax and respiratory arrest in experimental models when ongoing air accumulation occurred, while vented seals prevented these outcomes 3
• Research demonstrates that vented chest seals effectively evacuate both air and blood while preventing hemodynamic compromise 4

Critical Safety Monitoring

Mandatory Post-Application Surveillance

• Continuous monitoring for worsening breathing or symptoms is essential after any dressing placement. 1
• If breathing worsens after dressing application, immediately loosen or remove the dressing to prevent iatrogenic tension pneumothorax 1
• The primary concern is creating a one-way valve that traps air in the pleural space, converting an open pneumothorax into a fatal tension pneumothorax 1

Signs of Tension Pneumothorax Development

• Progressive worsening of respiratory distress 5
• Decreased air movement on the affected side 1
• Hypotension and cardiovascular compromise 1, 5

Common Pitfalls to Avoid

Never Use Fully Occlusive Dressings Without Venting

• Improper use of occlusive dressings can create iatrogenic tension pneumothorax by preventing air from exiting through the chest wound. 1
• This is the greatest concern with chest seal application and has been documented in medical literature since the 1950s 1

Evidence Limitations

• No human studies exist evaluating chest seals for patient-important outcomes (morbidity and mortality) 1
• Available evidence comes from porcine models and healthy human volunteers 1
• The skill level required for correct application is unknown 1

Makeshift Options

• Research demonstrates that rescue blankets applied wet can function as effective makeshift chest seals when commercial products are unavailable, with fixation on only 2 sides allowing trapped air to exit 6
• Plastic foils from gauze packages are inferior to rescue blankets for emergency chest seal applications 6

Special Considerations

Mechanically Ventilated Patients

• Any pneumothorax in mechanically ventilated patients requires tube thoracostomy rather than chest seals alone, as positive-pressure ventilation maintains the air leak 5

Definitive Management

• Chest seals are temporizing measures only; definitive treatment requires tube thoracostomy placement 5, 7