Page 103 - JSOM Spring 2021

from their environment. The study by Arnaud et al. shows or an impending tension pneumothorax. Because the civilian
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that vertical movements and soiled skin do pose strain to the population also experiences perforating thoracic wounds,
adhesive properties of chest seals. This implies that chest seals these healthcare providers should practice civilian guidelines.
be checked after a soldier is moved, similar to checking an ap- This implies the need for regular and repetitive training for
plied limb tourniquet after moving an injured soldier. 35 those working within the military and civilian rescue services
who are the most responsible for treating those wounded. Per-
All the eight guidelines providing recommendations for treat- haps a simpler training protocol could be to follow the guide-
ing sucking chest wounds/open pneumothorax are from lines related to the need for a chest seal application and then
leading organizations working in tactical and/or civilian pre- go on with more advanced training, as needed.
hospital trauma care. This author believed it was important
to include the guideline from the Chinese PLA because this NATO country militaries may have different training require-
provided information from outside NATO. Except for two of ments in invasive procedures, such as needle decompression.
the civilian-oriented guidelines, all recommended the use of According to Kotwal et al., not all military providers receive
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vented chest seals. 25,32,34,35,37,40 The ERC civilian guidelines do adequate training in tactical medicine, and also, not all com-
not recommend the use of an occlusive dressing because of the bat first responders are updated prior to a mission. This same
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risk in creating a tension pneumothorax. Perhaps this could need for training in more invasive procedure applies to the
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be because civilian medical personnel, in a symptomatic open civilian emergency medicine services. We must also discuss
pneumothorax patient, can often perform a more definitive prehospital invasive treatment by nonmedical personnel (e.g.,
therapy, such as needle decompression or chest tube insertion. police medics) to address tactical or austere environments.
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Overall, the guidelines recommend burping an applied chest
The guidelines of C-TECC recommend the use any chest seal, seal, as indicated by symptoms. It may also require insertion
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as long as other treatment options to relieve a tension pneu- of a decompression needle or a chest tube (see Table 3 and Re-
mothorax are available. They rely on short transport times to sults). However, it is important to be aware that the failure rate
an inpatient facility to assist in the preventing a tension pneu- of needle decompression, using a 14g, 3.25” needle, is as great
mothorax and provide a faster diagnosis. as 60%. Military organizations should evaluate whether
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there is a need to train their combat-first responders in the
The Royal College of Surgeons of Edinburgh, Scotland, rec- procedures of finger thoracotomy and/or tube thoracotomy.
ommended the use of the Asherman chest seal in 2007. This
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was prior to any published animal studies about the efficacy We need more data using various chest seals so that we may
of chest seals. In their updated 2016 guidelines, they recom- increase our understanding and knowledge in treating sucking
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mend the use of vented chest seals with no further specifica- chest wounds. Data collection can be difficult, and sometimes
tion. In contrast to other guidelines, they advise that further impossible, with chest seal use during tactical fighting and its
prehospital treatment is unnecessary for most patients. How- follow-up in tactical field care. Our best hope is for more stud-
ever, within their 2016 guidelines, they include additional rec- ies assessing the blood coagulation in vented chest seals. If a
ommendations related to performing a needle decompression vented chest seal is closed because of clotting, then it works as
or insertion of a thoracotomy tube. a nonvented chest seal. Another important clinical variation to
add to studies would be more realistic wounds that penetrate
The tactical-oriented guidelines have all adopted the results both the parietal and visceral pleura.
of the animal studies and recommend the use of vented chest
seals. TCCC was the first organization to change their recom- Conclusion
mendation, and the other organizations followed afterward. It
is interesting to note that most of the chest seals applied by the Both vented and unvented chest seals can stabilize the cardio-
of US military in Afghanistan were unvented. 10 respiratory parameters in a casualty with an open pneumo-
thorax. However, vented chest seals were the most efficient
It must become a priority that all mission-deploying military in evacuating air and blood in hemopneumothorax swine
personal be trained on the clinical signs of a tension pneu- models. This led to an overwhelming support of vented chest
mothorax. Following the TCCC guidelines, they should sus- seals. Because of the potential for training insufficiencies, it
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pect a tension pneumothorax in casualties with heavy thoracic is uncertain how valuable these results may be for their use
trauma or blast injury and on sucking chest wounds. Medical personnel who apply chest
seals to casualties with sucking chest wounds must provide
• Severe or progressive respiratory distress alert monitoring and recognize the signs of an impending or
• Severe or progressive tachypnea worsening tension pneumothorax.
• Absent or markedly decreased breath sounds on one
side of the chest Financial Disclosure
• Hemoglobin oxygen saturation <90% on pulse oximetry The author has no financial relationships relevant to this arti-
• Shock cle to disclose.
• Traumatic cardiac arrest without obviously fatal wounds
Author Contributions
Other physical signs may be chest pain, tachycardia, and re- VK conceived the paper concept, analysed the literature, and
duced expansion of the thorax. 20,48,49 Signs in ventilated pa- wrote this article.
tients will be different—for example, crepitus of the skin or
an increase in ventilation pressure. 20,48 Every military first re- References
1. Belmont PJ Jr, McCriskin BJ, Sieg RN, Burks R, Schoenfeld AJ.
sponder, and all medical military personnel, must be capable of Combat wounds in Iraq and Afghanistan from 2005 to 2009. J
diagnosing and treating what may be a tension pneumothorax Trauma Acute Care Surg. 2012;73(1):3–12.

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