65.7 Open chest wounds

If a patient has an open chest wound, his injured pleural cavity fills with air (sometimes under tension), his lung collapses, he is in great respiratory distress, and he may die. There may be a sucking noise each time he breathes, or froth from his injured lung may come out of the hole in his chest—a sucking chest wound is an extreme emergency.

Teach your ambulance driver to put an occlusive dressing on open chest wounds. These need a surgical toilet, just like any other wound, but the patient’s pleural cavity must be closed. Sucking wounds of the chest, including most gunshot wounds, need a thoracotomy. If you cannot refer a patient, you may be able to treat him, as described below.

MIHAIL (47) sustained a severe open chest injury with multiple fractured ribs and a haemopneumothorax. The consultant told his house surgeon to "get on with it". With the help of the anaesthetist he closed the patient’s open wound, transfused him, and intubated and anaesthetized him. The house surgeon had never seen a thoracotomy. Even so, he enlarged the chest wound, and toileted it. The anaesthetist was able to get some air into the collapsed lung. The patient’s ribs were brought, together with Kirschner wire, his chest closed with continuous sutures, and drained with an underwater seal, after which he recovered completely.

OPEN CHEST WOUNDS

Can you hear air being sucked into the patient’s pleural cavity each time he breathes? Is his trachea or apex beat displaced? If so he has a sucking chest wound. He may also have a tension pneumothorax.

EMERGENCY TREATMENT Block the hole with a pad made of several thicknesses of vaseline gauze and dry gauze. Keep it in place with adhesive strapping. If this is not available, use anything convenient.

ANAESTHESIA For large injuries intubate the patient and give him trichlorethylene or a ketamine drip with relaxants (A 8.4). For small injuries use intercostal blocks.

OPERATION Clean the patient’s wound, and tie off any bleeding vessels. if you decide to probe, do so cautiously. Do a careful wound toilet. You will be wise to leave most foreign bodies where they are. Remove broken fragments of rib and muscle.

Close the patient’s pleura. If possible, try to close his wound by suture. If this is not possible, close it with flaps of near by skin and muscle. If necessary, use Kirschner wire to thread together the ends of any fractured ribs.

If the patient’s wound is heavily contaminated, close his pleura, but leave his skin wound open for delayed primary closure.

Insert two intercostal drains, one just below his clavicle to remove air, on one just above his diaphragm posteriorly to remove fluid (65.2). if you suture his skin without inserting a drain he may get massive surgical emphysema.

Figure 65.11: ASPIRATING A PATIENT’S PERICARDIUM from under his xiphoid process. After Naclerio, with kind permission.