Sealing a ‘sucking’ chest wound
Emergency life-saving procedure to manage chest cavity with open wound
Attention
- Do not use gauze or combine to seal wound, may cause tension pneumothorax
- Never take out object that is sticking into chest (eg knife, spear)
- Person will need
- IV cannula
- Oxygen to target O₂ sats 94–98% OR if moderate/severe COPD 88–92%
- Probably a chest drain
What you need
- Sterile gloves
- Piece of thin, flexible, waterproof paper or material a bit bigger than wound (eg
Op-site or defibrillator pad packet, thin strong paper)
- Tape
What you do
- Put on sterile gloves
- Cover wound with waterproof paper and seal well with tape on 3 sides, leaving bottom
edge free — Figure 3.37
- Forms vacuum seal around wound when person breathes in but lets air in chest cavity
escape when person breathes out
- Allows blood to drain from wound
Needle decompression of tension pneumothorax
Emergency life-saving procedure to let out air trapped in chest cavity when lung collapsed. Makes breathing easier
and improves BP
Need to act very quickly
Attention
If/when plastic cannula blocks the tension pneumothorax can come back. Put in new
cannula as needed, close to the original position
Look for
- Signs of injured side of chest (localising signs)
- Tenderness, bruising, crepitus/crackling on palpation
- Hollow sound when tapping
- Reduced air entry, reduced movement
- Trachea (windpipe) has moved away from this side (deviation). Often hard to see/feel
- Generalised signs
- Severe shortness of breath
- Person very frightened
- Diaphoretic (heavy sweating)
- Bulging of neck veins — late sign
- Severe shock — pre-terminal sign
- Cardiac arrest with pulseless electrical activity (PEA) — terminal sign
What you need
- Gloves (sterile not necessary — life-threatening problem)
- Alcohol wipes
- 14G non-retractable cannula (several)
- 20mL syringe (optional)
What you do
- If person conscious — explain procedure
- Leave person in position they find most comfortable
- Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD 88–92%
- Non-rebreather mask 10–15L/min
- Find site for needle — space between second and third ribs (intercostal space) in
mid-clavicular line — Figure 3.38
- Clean site with alcohol wipe
- Put in cannula to full length at 90° to chest wall and just above upper edge of third
rib (to avoid neurovascular bundle) — Figure 3.39
- Can use 20mL syringe attached to cannula needle.
- Allows release of air on entry to pleural space
- If air doesn’t whoosh out when you put needle in
- Make sure you are in injured side. See signs of injured side of chest
- If confirmed in the injured side — try another location closer to armpit (laterally)
in same rib space
- Remove metal needle, leaving plastic cannula in place. Shouldn't need to be taped
- Check breathing regularly to make sure it is improving
- Put in proper chest drain as soon as possible. Leave cannula in until then
Chest drain
Intercostal chest drain lets out air or blood trapped in chest cavity and makes breathing
easier
- Use after doing needle decompression
- If person stable, can be delayed until help arrives
Attention
- Never use big metal trocar that comes with chest drain to make hole in chest
- Always put drain into chest by going directly above top of lower rib. There are blood vessels and nerves along bottom of ribs
- If haemothorax — blood may come down drain tube as well as air
What you need
- Helper
- Marking pen
- Sterile dressing pack
- Sterile gloves
- Sterile gauze
- Povidone-iodine or chlorhexidine in alcohol antiseptic solution
- Sterile towels/drapes
- Sterile scalpel
- 10mL syringe and long 23G needle
- 2 ampoules (10mL) of lidocaine (lignocaine) 1% + adrenaline (epinephrine) (1:100,000)
- 2 long artery forceps (eg large Kelly haemostats)
- Intercostal drain plus
- Heimlich valve OR underwater seal device
- Suture set with 3.0 silk/nylon/prolene for skin closure
- Strong suture for securing tube — size 1 mersilene or size 2 silk
- Vented urine/fluid collection bag, set and tubing
- 2 large clear dressings
- Intercostal catheter. Size guide — use smaller size for draining air, larger size for draining blood/fluid
- Newborn 8–12G
- Infant 12–16G
- Child 16–24G
- Adolescent 20–32G
- Adult 28–32G
What you do
- If person conscious — explain procedure
- Position person, supported by pillows with hand behind head on injured side to expose
as much of chest and axilla (underarm) as possible — Figure 3.40
- Attach available monitoring equipment (eg BP, ECG, O2 sats) put in IV cannula
- Give oxygen to target O2 sats 94–98% OR if moderate/severe COPD 88–92%
- Non-rebreather mask 10–15L/min
- Painful procedure — give morphine IV as analgesic and sedative
- Mark site with marking pen — Figure 3.41
- Fourth or fifth intercostal space just anterior (in front) of mid-axillary line (lower
middle of armpit)
- Count rib spaces at front and follow them backward to mid-axillary line with finger.
Fourth space is about 3 finger widths below armpit, above level of nipple — Figure 3.41
- Lay out equipment — not metal trocar
- Use forceps to clamp tube closed at far end
- Open Heimlich valve, check which end connects to intercostal drain —it is marked Figure 3.42 OR prepare underwater drain following manufacturer instructions
- Clean site, drape with sterile towels if possible
- Infiltrate with 10mL (adult) lidocaine (lignocaine) + adrenaline (epinephrine) with needle and syringe. Aim to anaesthetise area in intercostal space about 4–6cm
wide
- Give in 2 lots, checking for withdrawal of blood each time
- Give 5mL just under skin
- THEN give 5mL along top edge of rib below (to avoid neurovascular bundle) — Figure 3.43, Figure 3.44
- When air aspirated you have reached pleural cavity
- Begin infiltrating as you withdraw needle slowly so anaesthesia includes pleura
Remember: Anaesthetic takes a few minutes to work
To put in drain
- Use scalpel to make 3–5cm incision through skin, above and parallel to rib below —
Figure 3.45
- Use artery forceps to blunt dissect. Open and close against muscle to separate tissue
down to pleura — Figure 3.46
- Support forceps so you are not too forceful — Figure 3.47
- Will feel a pop and change in resistance as you enter pleural cavity
- Open forceps in all directions to enlarge hole
- Replace forceps with gloved finger — Figure 3.48
- Sweep finger around gently in all directions to clear away any tissue — Figure 3.49
- Make sure you are in chest cavity by feeling the inside surface of ribs with fingertip.
You may or may not feel the lung against your finger
- Guide tip of tube in beside gloved finger and aim drain up toward top of lung. Use
forceps to help — Figure 3.50
- Push drain at least 2cm past last hole seen in tube. More if person has more fat
To connect Heimlich valve or underwater seal
- Look for fogging in tube this is a good sign
- Connect Heimlich valve OR underwater seal
- Release forceps clamping end of tube
- Check for valve flapping OR bubbling/swinging of water
- Collect blood or fluid in vented urine/fluid bag
- Leave bag vent open to allow draining air to escape. If no vent — cut small hole at
top
To make drain secure
- Close wound each side of drain with interrupted sutures
- Tie long ends of suture material firmly around tube to hold in place. Do not use purse string suture
- OR suture tube in place with separate 1.0/2.0 silk or polyester (eg Mersilene) stitch 1cm from wound edge. Tie knot compactly, tight enough to indent tube
- Cover with see-through dressing
- Make sure tube not kinked
- Check valve still flapping OR water still bubbling/swinging
Re-expanding lung is painful. May require extra morphine now