Treatment

Definitive treatment is surgical repair. Your job is to alleviate any respiratory embarrassment, exclude associated injuries and identify the need for timely thoracotomy or laparotomy.

• Cover the wound taping down three sides only, in order to allow expired air to escape, if not already done so by the paramedics. Sheets of Jelonet or any other impermeable membrane will do. Specific chest seal devices (Ashermann or Bolin) exist (image, below).
• If the hole is too big for either of the above, then cover with a large opsite, make a small hole in the middle and place a chest seal device on top (if available).
• Temporarily release any wound dressing over the open pneumothorax if you suspect tensioning.
• Early intubation — IPPV solves the respiratory embarrassment created by the hole in the chest. Your patient is likely to be heading for CT scan, if not theatre.
• For small open pneumothoraces, insert a chest drain remote from the wound on that side — practically easier once the patient is anaesthetised.
• Do not insert a chest drain in patients with a large open pneumothorax since muscle flaps may be needed for closure and can be damaged in the procedure.

Fig 6: Chest seal devices