Occurs when a chest wall opening is larger than two-thirds of the cross-sectional area of the trachea.
1. Rapid Clinical Assesment
- ABCDE Approach
- Monitoring and Oxygenation:
- Put on high flow mask
- Maintain SpO₂ > 95%.
- Place the patient on a cardiac monitor.
- Establish intravenous (IV) access.
2. Identification:
LOOK
i. Open Wound on the Chest Wall:
- Visible penetrating injury such as stab wounds, gunshot wounds, or impalement.
ii. Bubbling or Sucking Sounds:
- Air movement through the wound may cause bubbling of blood or a sucking noise, especially during inspiration.
iii. Respiratory Distress:
- Signs include tachypnea (rapid breathing), use of accessory muscles, cyanosis, and agitation.
iv. Asymmetrical Chest Movement:
- Reduced expansion on the affected side due to lung collapse.
LISTEN
i. Noisy Movement of Air Through the Wound:
- Audible sounds of air entering and exiting the chest wall defect.
ii. Reduced Breath Sounds Over Ipsilateral Side:
- Diminished or absent breath sounds upon auscultation on the side of the injury.
iii. Possible Hyperresonance:
- Percussion may reveal a hyperresonant (tympanic) sound due to air accumulation.
FEEL
i. Hyperresonance on Percussion Over the Affected Side:
- Indicates the presence of excess air in the pleural space.
ii. Subcutaneous Emphysema:
- Air may escape into subcutaneous tissues, causing a crackling sensation upon palpation.
iii. Tracheal Position:
- The trachea may be midline initially but can deviate if a tension pneumothorax develops.
3. Three-Sided Occlusive Dressing:
- Cover the open chest wound with a sterile, occlusive dressing (e.g., Vaseline gauze, plastic wrap) secured on three sides.
- The unsecured fourth side acts as a flutter valve, allowing air to exit during exhalation but preventing air from entering during inhalation.
4. Definitive Management:
i. Chest Tube Insertion (Thoracostomy):
- Inserted at a site away from the open wound, typically in the fifth intercostal space at the mid-axillary line.
- Allows continuous evacuation of air and re-expansion of the lung.
ii. Consult for Surgical Repair
iii. Supportive Care:
- Oxygen Therapy:
- Administer high-flow supplemental oxygen to correct hypoxia.
- Analgesia:
- Provide pain management to improve respiratory effort.