What is the prehospital management of a patient with a penetrating chest injury causing an open pneumothorax?

Prehospital Management of Open Pneumothorax from Penetrating Chest Injury

Immediately activate emergency medical services, apply a clean non-occlusive dry dressing (such as gauze) or leave the wound exposed to ambient air, and continuously monitor for worsening respiratory status—if breathing deteriorates after any dressing is applied, immediately loosen or remove it to prevent iatrogenic tension pneumothorax. 1

Immediate Actions

Activate Emergency Response

• An open chest wound is a medical emergency requiring immediate activation of the emergency response system. 1
• The wound penetrates through the chest wall into the pleural cavity, creating direct communication between the external environment and the lung space. 1

Wound Management Options (in order of preference)

The 2024 American Heart Association guidelines provide three equally reasonable first-line approaches:

• Apply a clean, non-occlusive, dry dressing (e.g., gauze dressing or part of a T-shirt)—this is the preferred option when materials are immediately available. 1

• Leave the wound exposed to ambient air—this is acceptable when no dressing is available or when application might delay other critical interventions. 1

• Apply a specialized vented chest seal—this may be considered for large chest wall defects from high-velocity rifle wounds, shotgun wounds, or blast injuries that create substantial air entry during inspiration. 1, 2

All three options carry a Class 2a recommendation (reasonable to perform) based on expert consensus. 1

Critical Distinction by Wound Size

• Small penetrating wounds (stab wounds, most handgun injuries, many rifle wounds) typically do not produce clinically significant air leak and generally do not benefit from chest seal application. 2

• Large chest wall defects (high-velocity rifle, shotgun, blast injuries) are the primary candidates for chest seal placement because they allow substantial air entry that impairs normal ventilation. 1, 2

Continuous Monitoring Protocol

Essential Surveillance

• Continuously monitor the patient for any worsening of breathing or new symptoms after any dressing is placed. 1, 2

• If respiratory status deteriorates, immediately loosen or remove the dressing—this may relieve an iatrogenic tension pneumothorax. 1, 2

Recognizing Tension Pneumothorax

• Progressive, rapidly worsening respiratory distress with labored breathing distinguishes tension from simple pneumothorax. 3

• Attenuated or absent breath sounds on the affected side are the most reliable bedside finding. 3

• Hypotension, tachycardia, cyanosis, and profuse sweating indicate hemodynamic compromise. 3

• Tracheal deviation is unreliable—it was absent in all 111 cases reviewed in one military trauma database. 3

Critical Pitfalls to Avoid

The Occlusive Dressing Hazard

• The greatest concern is creating a one-way valve that allows air to enter the pleural space during inspiration but prevents exit during expiration, converting an open pneumothorax into a fatal tension pneumothorax. 1, 2

• The 2015 American Heart Association guidelines explicitly recommended against the application of occlusive dressings by first aid providers (Class III: Harm) due to this risk. 1

• The 2024 guidelines evolved to allow vented chest seals for large defects, but emphasize that any dressing—occlusive or not—requires continuous monitoring and immediate removal if breathing worsens. 1

Common Misconceptions

• Do not assume the open wound provides adequate decompression—the wound can become occluded by tissue, clot, or dressing, and cannot reliably decompress the pleural space. 4

• Even with an open wound present, definitive tube thoracostomy remains necessary for any pneumothorax or hemothorax. 4

• Approximately 32% of patients require repeat intervention after initial needle decompression alone, underscoring that temporizing measures must be followed by definitive care. 3

Evidence Limitations and Practical Implications

• No human outcome studies exist for chest seal use in open pneumothorax—current evidence derives from porcine models and healthy volunteer studies. 2

• The skill level required for correct chest seal application remains undefined. 2

• Research from the U.S. Army Institute of Surgical Research found that vented chest seals prevented tension pneumothorax development whereas non-vented seals did not in experimental models. 5

• A civilian trauma series showed that strict adherence to ATLS protocol (three-way occlusive dressing followed by chest tube) resulted in zero mortality, but 83% of patients with protocol violations developed life-threatening tension pneumothorax. 6

Definitive Care Transition

• All penetrating chest injuries with pneumothorax or hemothorax require closed thoracic drainage (tube thoracostomy) as definitive treatment, regardless of wound size or appearance. 4

• The chest tube is placed in the 4th-5th intercostal space along the mid-axillary line and connected to an underwater-seal drainage system. 4

• If tension pneumothorax develops, perform immediate needle decompression at the 2nd intercostal space, mid-clavicular line using a 7-8 cm needle (not the traditional 5 cm needle, which fails in 33% of cases), followed immediately by tube thoracostomy. 3