Page 101 - JSOM Spring 2021

and packaged, may be inferior if applied under stress during a not necessarily linked to the use of a chest seal, within their
combat situation. All studies reported above are summarized full guidelines. 32,34,35,40–42
16
in Table 2.
Discussion
Following this author’s search strategy for international
guidelines, 1,059 papers were found on PubMed. Google and Military and civilian first-line care providers should not over-
professional knowledge searches cannot be specifically quan- look how important it is to have available the best scientific
tified. Two guidelines were excluded because the publication data in the treating of sucking chest wounds.
year was before 2010. 32,33 These institutions’ guidelines were
identified: the Joint Trauma System (USA), Tactical Combat For this review, five original studies were identified that re-
34
Casualty Care (TCCC; USA), the Tactical Rescue & Emer- ported test results on the use of chest seals and their efficacy
25
gency Medicine Association (TREMA e.V.; Germany), Inter- in treating sucking chest wounds. Three of these studies tested
35
national Trauma Life Support (ITLS; USA), the European various vented chest seals in a swine model of open hemo-
36
Resuscitation Council (ERC; Europe), the Royal College of pneumothorax. Most of the vented chest seals stabilized the
37
Surgeons of Edinburgh (Great Britain), the Committee for cardiorespiratory parameters after being applied to a sucking
32
Tactical Emergency Combat Care (C-TECC; USA), 38,39 and chest wound. They were also effective in evacuating any addi-
the Chinese People’s Liberation Army (PLA). An overview is tional air injected into the pleural space. 28,29,31 Unvented chest
40
provided in Table 3. seals were effective in treating an open pneumothorax, but a
tension pneumothorax developed after the injection of addi-
All guidelines, except the C-TECC and ERC, recommend the tional air. 30
use of vented chest seals for first-line treatment. The C-TECC
believes that vented chest seals are not superior to unvented Specific testing of vented chest seal adherence on swine skin
chest seals when other treatment options are available to pre- was the purpose of the study by Arnaud et al. in 2008. Re-
16
vent a tension pneumothorax. The ERC recommends not to sults were comparable for four of eight chest seals under ex-
38
cover chest wounds with any occlusive dressing at all. The treme temperatures. Furthermore, vertical strain seemed to be
37
guidelines of the C-TECC, PLA, TCCC, TREMA e.V., and more stressful to the chest seals than horizontal strain, specifi-
Royal College of Surgeons of Edinburgh link the use of chest cally when used on skin contaminated with sand and blood. 16
seals and the appearance of signs indicating a tension pneumo-
thorax. In case of a suspected developing tension pneumotho- The study by Kheirabadi et al. in 2013 found that unvented
30
rax, the applied chest seal should be lifted (“burping”), and a and vented chest seals stabilized an open pneumothorax.
needle decompression or thoracostomy should be performed When a chest wall defect was the only way for air to enter the
if required. 25,32,35,38–40 Many of these guidelines provide more pleural space, application of a chest seal prevented the sucking
detailed information regarding the diagnosis and treatment, chest wound from functioning in one direction and prevented
TABLE 2 Overview of the Studies Reporting the Efficacy of Different Chest Seals in the Treatment of Sucking Chest Wounds
No. of Unvented
Studied Studies Method n Vented Seals Seals Results
Occurrence of 4 Injection of air 8 28 Asherman; N/A • Tension PTX with no seal application
tension PTX in & blood Bolin • No tension PTX with seal application
swine models 8 29 HyFin; SAM; N/A • Tension PTX with no seal application
Sentinel • In 20/24 cases no tension PTX with seal
application
8 30 Bolin Halo • ↓ SvO , SpO and PaO 2
2
2
• Parameter stabilization post vented & unvented
seal application
• Tension PTX with continued air injection with
unvented seal
• No tension PTX with continued air injection with
vented seal
26 31 HyFin; Russell; N/A • ↓ SvO , PaO cardiac output and lung volume
2
2,
Sentinel; Bolin; • ↑ Intrapleural pressure
SAM • All seals restored intrapleural pressure
• Laminar vented seals (HyFin; Russel; Sentinel)
prevented tension PTX
• Flutter vented seals (Bolin ; SAM ) had a 25%
™
®
occurrence of tension PTX
Adhesive strength 1 Dry vs: moist/ 8 28 Asherman; N/A • Asherman chest seal significantly less adhesive on
in swine models bloody skin Bolin moist/bloody skin
1 Dry vs: bloody/ 26 16 Asherman, N/A • 3 seals excluded due to poor adhesive qualities
sandy skin Bolin, Sentinel, immediately recognized (Asherman, Sentinel,
Bolin XL, Bolin XL)
FastBreathe, • 5 seals included (FastBreathe, HyFin, Russel,
HyFin, Russell, SAM, Bolin) – with the exception of Bolin
SAM showing comparable results
• Vertical strain more stressful than horizontal
strain
PTx = Pneumothorax
Chest Seals in Treating Sucking Chest Wounds | 97