Page 146 - Journal of Special Operations Medicine - Winter 2014

Best Practices: An Ongoing Series

Management of Open Chest Wounds in

Tactical Emergency Casualty Care:
Application of Vented Versus Nonvented Chest Seals

Asa M. Margolis, DO, MPH, MS; Nelson Tang, MD, FACEP;
Matthew J. Levy, DO, MSc, FACEP, NRP; David W. Callaway, MD, FACEP

ABSTRACT
The 2014 midyear, full meeting of the Committee for There continues to be a lack of data suggesting that
Tactical Emergency Combat Care (C-TECC) was hosted improvised three-sided dressings are reliably effective
by the Johns Hopkins University Center for Law En- either in reversing respiratory compromise from an
forcement Medicine on June 9 and 10 in Baltimore, open pneumothorax or in preventing the conversion
Maryland. As the C-TECC guidelines are increasingly to a tension pneumothorax. Battlefield conditions are
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recognized as the best-practice recommendations for highly variable and can impact improvised chest-seal
civilian, high-threat, prehospital trauma response, a application. Commercially available chest seals take less
focused guidelines discussion occurred to develop best- time to apply, typically offer greater adhesive proper-
practice recommendations for the management of open ties, and eliminate variation in practice, including pro-
chest wounds, specifically regarding the application of vider skill and availability of suitable dressing material.
vented and nonvented chest seals. Despite the advent of multiple commercially developed
chest-seal products, concern regarding the potential to
Battlefield casualty care experience continues to be an “convert a sucking chest wound into a life-threatening
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invaluable resource to civilian prehospital trauma care, tension pneumothorax” has persisted.
both in the emergency medical services (EMS) and tacti-
cal medicine arenas. Against a backdrop of the ongo- Penetrating torso trauma and tension pneumothora-
ing threat of penetrating torso trauma, the optimal field ces remain a leading potentially preventable cause of
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management of open chest wounds continues to be a death in combat. The recent Tactical Combat Casualty
focus of scientific investigation and clinical decision Care (TCCC) Guideline Change 13-02 for management
making. Historically, the widely practiced prehospital of penetrating chest trauma and open pneumothorax
management of such injuries has been the application places new emphasis on the use of vented chest seals.
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of typically improvised three-sided occlusive dressings. The Committee on Tactical Combat Causality Care
With the now widespread availability of commercially (CoTCCC) qualified these recommendations as “Level
developed chest seals, there remains active consider- of evidence: Level C” based on American College of
ation of the potential advantages and limitations of both Cardiology/American Heart Association guidelines. The
vented and nonvented chest seals. new CoTCCC recommendation was based on evidence
from two recent laboratory animal trials.
Recognition of at least the possibility of the development
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of a tension pneumothorax following the application of In a study by Kheirabadi and colleagues, a swine model
a completely occlusive dressing to an open pneumotho- was used to assess for the development of a tension
rax is not new. This was, in fact, the driving rationale pneumothorax, comparing vented and nonvented chest
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behind the field application of three-sided field dressings seals. Increments of 200mL of air were injected into
to open chest wounds. Improvised dressings of this type, the pleural cavity every 5 minutes until either tension
however, are no longer a first-line recommendation. pneumothorax developed or the volume of air injected
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