Chest wound treatment and complications

[u/Drtyler2]

I was always told to put a chest seal on any bleeding wound within the chest cavity or abdomen. However, new data has proven that, while vented chest seals are theoretically useful, they often fail, leading to increased risk of TP.

So what is the best intervention for a wound in the chest or abdomen? Will an IPD work? Also, when it comes to chest seals AND occlusive dressings within the chest and abdomen, what is the risk of internal bleeding? We’re not compressing the arteries after all.

I’ve been told that there is no proper treatment for internal bleeding in the field, and the best course of action is to get them to a higher level of care ASAP. But if extraction is some time away, is there any measures we can take? If not, are we SOL, or is it not as urgent as I believe?

[u/OddAd9915]

All interventions may fail, and the likelihood will only go up in an adverse/non permissive environment. So once the casualty is in a place of relative safety reassessment of all the interventions is essential to ensure a TQ hasn't slipped or come loose, chest seals aren't blocked etc.. Chest seals aren't intended to stop bleeding, they are there to reduce the risk of tension, the reason they get used on abdominal injury as well is to seal the wound and reduce the risk of infection or bowel being pushed out of the wound, you could push packing gauze into the wound until the cows come home and almost certainly wouldn't compress the bleed enough to make a difference.

Penetrating trauma to the chest has very limited non surgical options. If your skill set and scope of practice allows, you can decompress the chest or do a blunt/finger thoracotomy to reduce the risk of tension disease, but they will still require significant and timely surgical intervention.

Abdominal injury may offer slightly more options if the wound is big enough to visualise any bleeding vessels that you can then try and apply pressure directly to, but the options again are very limited without surgery, and probably the time is better spent on removing the casualty as far towards definitive care as possible.

Ultimately the casualty require a surgeon for any penetrating trauma. All you can try to do it buy them enough time to get to the surgeon. Fluid resuscitation, effective packaging with as gentle handling as possible to minimize clot disruption and a swift extraction to higher care are the things you can do. 

[u/Drtyler2 → u/OddAd9915]

Thank you. How would I stop the bleeding on an abdominal/chest wound then? And what procedures can I take to prolong their life until a higher level of care is reached?

[u/OddAd9915 → u/Drtyler2]

You can't really, unless you are able to visualise the vessel and apply direct pressure with something like haemostatic gauze. You might be able to do this with a more surface wound but if vessels inside the chest cavity are bleeding there is basically FA that you can do with a clamshell thoracotomy, which would probably only be done in a TCA or peri TCA situation on a MERT flight or with HEMS as it's absolutely a surgical intervention.

What can be done without surgery: fluid replacement, TXA, careful handling to minimize loss of any clots that have formed, keeping them warm and expeditious movement to somewhere that can do the emergency surgical interventions. 

[u/Drtyler2 → u/OddAd9915]

Well shit. Appreciate it though. Could you explain some of those acronyms for me? I’m a layman when it comes to this shit, and google ain’t helping.

[u/OddAd9915 → u/Drtyler2]

Apologies. 

TXA is Tranexamic acid, a antifibrinolyitic medication that stops clots that have already formed from breaking down as easily. Just an abbreviation because it's a mouthful.

MERT is the Medical Emergency Response Team, British military medivac teams that compromise of combat medics and Drs to collect casualties from near the front line and move them to a field hospital and have the capability to deliver a significant amount of surgical intervention while on route as damage control.

HEMS Helicopter Emergency Medical Services, the UK equivalent of life flight but in the UK all have both a paramedic and Dr on the team and again can deliver some surgical intervention prehospital. 

TCA is a Traumatic Cardiac Arrest. Peri simple means an impending arrest, be it traumatic or medical.

FA is just Fuck All ;)

[u/Drtyler2 → u/OddAd9915]

Thank you!

And excuse my ignorance, but would Celox granules be able to get in there and directly clot the wound? Or would there be complications? Also, when you say fluid replacement, do you mean utilizing blood substitutes?

[u/OddAd9915 → u/Drtyler2]

Celox granules so specifically say for external use only on the package. So it would be going directly against the manufacturers instructions and probably using it in a way it's not designed or tested for. 

All celox products require direct pressure to be effective, so pouring them into a cavity blindly will probably do nothing and will waste time that can be better spent on other interventions or simply moving the casualty onward, admittedly not much time but it's still wasted effort really. 

[u/rima2022]

Chest wounds don't bleed the same way arterial bleeds do. Chest seals are to be used for entry and exit wounds. You don't pack chest wounds because it is a cavity, you'll be packing forever. I would not recommend celox granules either. Chest seals are literally a bandaid. It's not a cure, higher levels of care are needed. They're not going to stick forever either Additionally, tension pneumothorax takes about 20 minutes to develop, and chest seals wouldn't necessarily be the cause. And if it does develop, then treat with a needle decompression of the chest. Would be interested in seeing this new data about vented chest seals you mention however.

Abdominal wounds below the chest cavity need to be cleaned and packed depending on the severity/uncontrolled bleeding and if there is evisceration, a wet trauma bandage should be put over the organs and wrapped with cling flim or secured with chest seals to keep the organs from drying out.

There is nothing you can do at your level for internal bleeding. The casualty needs a surgeon.

[u/lookredpullred]

Chest seals increase incidence of tension pneumothorax. If I recall correctly there has never been a documented battlefield death from a true “sucking” chest wound, and 0.5% of penetrating trauma to the chest becomes “sucking” chest wounds.

To put that in perspective, if you had 200 patients that were shot in the chest, exactly one guy would benefit from a vented chest seal. And even then, often times the “sucking” chest wound also allows air to escape.

If you’re putting on chest seals for whatever reason still, you need to be prepared to decompress the chest.

[u/PerrinAyybara → u/lookredpullred]

There is a ratio to the size of the house compared to the airway. Large enough to pull air is also large enough to just kill you outright

[u/lookredpullred → u/PerrinAyybara]

Yes, 2/3 the size of the trachea, or the size of a dime for adult men.

[u/Low-Landscape-4609]

They need a higher level of care.

The reality is, a lot of tactical medical training is designed to teach people how to do something but it doesn't mean it's going to work.

You have a lot more resources in the back of the ambulance than you do in a small medical bag. Some of the best paramedics in the world are just highly trained first aidsmen without a lot of the equipment on the ambulance.

[u/Joliet-Jake]

While it’s true that chest seals can fail, that doesn’t mean that you shouldn't still use them. It’s just not a “set it and forget it” deal. Reassess and correct any issues as often as possible.

[u/bleutheory → u/Joliet-Jake]

This! More people need to understand how important this is. Reassess, reassess, reassess. The patient is like a picture and the vitals are the description. When you look at them individually you can guess at what the context is and maybe you will get the right answer, but when you have both together it makes it much more complete.

[u/bleutheory]

I love this toppic. seriously, i use it all the time when teaching students.

so, the chest cavity? it works like a vacuum negative pressure keeps the lungs inflated,

but if there’s a hole in the chest, air rushes in to equalize with atmospheric pressure.

when someone breathes in, air enters the pleural space, turning that negative pressure to neutral or even positive.

as medics, we’re trained to slap a chest seal (like a sticker) over any hole we find.

if the only damage is to the chest wall, boom we’ve fixed it.

no more air sneaking in through the chest wall.

but in the military, injuries are rarely that simple.

often, the lung itself is damaged too.

so even with a chest seal, air leaks from the lung into the chest cavity.

some chest seals let a bit of air escape, but not enough.

over time, pressure builds up, turning a pneumothorax into a tension pneumothorax

first treatment? we “burp” the chest seal lift it slightly to let trapped air out.

this gives us time to monitor vitals and understand what’s going on.

and guess what? it works. Now what? If i lseave the chest seal on then I know I will have to keep burping the wound and can actually almost calculate how long it will take for that preasure to turn back from neutral to positive. If I take the chest seal off completely then I have created the ability for air to go out and in meaning permanent atmospheric pressure. So now i have to decide what is worse? Do i leave it on createing ther perfect environment for a tension pneumothoraxe or for i burp it to try to just releive the pressure? Thats where medics need to know, what is the problem, why id this problem an issue, what happens if I leave the injurt un treated, and last how do i wat to die> by slaughter? or live as a herro

say it takes 30–45 minutes to get the patient to advanced care.

that burp can be a lifesaver.

[u/PerrinAyybara → u/bleutheory]

Except that air won't go in because the wound is so small, it won't pull negative because the airway is so large. Easiest path for pressure differentials are most often NOT the wound but the airway.

[u/bleutheory]

I absolutely love teaching about chest injuries because it’s both fascinating and vital for saving lives. Our chest cavity works like a vacuum, using negative pressure to keep our lungs inflated. If there’s a hole in the chest wall, air rushes in to balance with the outside pressure, which can cause the lung to collapse. Medics apply a chest seal to cover the hole and stop more air from entering. If only the chest wall is damaged, this usually fixes the problem. However, in military situations, injuries often involve the lung itself, allowing air to leak into the chest cavity even after sealing the external wound. This trapped air can build up pressure, leading to a dangerous condition called tension pneumothorax, where the lung collapses and the heart gets compressed. To relieve this, medics “burp” the chest seal by lifting a corner to let the trapped air escape. This simple action can be a lifesaver, especially when it might take 30–45 minutes to get the patient to advanced care. Deciding whether to keep the seal on and manage the pressure or remove it entirely depends on the situation, and medics must assess the risks and benefits to make the best choice for the patient’s survival. As for the internal bleeding as medics there isnt much we can do. Maybe some TXA, but ultimately that is a surgical problem. 

[u/Drtyler2 → u/bleutheory]

I can see why you’re a teacher. Both comments were very informative in a very easy to learn/condensed manner!

[u/bleutheory → u/Drtyler2]

Haha sorry I replied twice. When I wrote the first comment and pressed reply it disappeared and didn't show it posted so I wrote a more condensed one.