Open Wound of the Chest

First aid for an open chest wound

1. Call 911 or your local emergency number. Do this first, or have someone else do it while you help.
2. Make sure the scene is safe before approaching, especially after shootings or stabbings.
3. Control bleeding. Press firmly on the wound with a clean cloth or gauze. Keep pressing. If blood soaks through, add more on top rather than removing the first layer.
4. Do not seal the wound airtight unless you are trained and have a vented chest seal. Current first aid guidelines from the American Heart Association and Red Cross advise lay rescuers to leave an open chest wound open to the air, or covered only loosely with a non-airtight dressing, because an airtight cover can trap air and cause a tension pneumothorax.
5. Leave any impaled object in place. Pulling out a knife or stick can cause catastrophic bleeding. Pad around it to stop it moving.
6. Position the person sitting up or leaning toward the injured side if they are conscious and breathing is easier that way, unless you suspect a spinal injury. If they become unresponsive and stop breathing normally, start CPR.
7. Look for other wounds, especially an exit wound on the back with gunshot injuries.
8. Keep them warm and still, and do not give food or drink.

Why bubbles appear around an open chest wound

Normally the space between the lung and the chest wall (the pleural space) has slightly negative pressure, which keeps the lung inflated against the ribs. When a wound opens this space to the outside air, every breath in sucks air through the hole instead of down the windpipe. This is called an open pneumothorax or sucking chest wound.

You may see:

• bubbles or frothy blood at the wound as air moves in and out
• a sucking or hissing sound with each breath
• the lung on that side collapsing, so breathing becomes fast and shallow

If the wound is large (bigger than about two-thirds of the width of the windpipe), air enters more easily through the wound than through the airway, and breathing becomes very ineffective.

Types of chest wounds

Wounds anywhere between the nipples and the shoulder blades (the "cardiac box") can injure the heart or great vessels. Wounds below the nipple line can pass through the diaphragm into the liver, spleen or stomach.

Symptoms

• Pain at the wound, often sharp and worse with breathing
• Shortness of breath and fast breathing
• Bubbling or sucking at the wound
• Coughing up blood
• Bluish lips or skin
• Signs of shock from blood loss: pale, cold, clammy skin, a fast weak pulse, dizziness, confusion
• Swollen neck veins, falling blood pressure and muffled heart sounds, which suggest tension pneumothorax or tamponade
• A crackling feeling under the skin (subcutaneous emphysema), from air leaking into tissue

Hospital assessment

Trauma teams follow a set order: airway, breathing, circulation. Assessment usually includes:

• Rapid bedside ultrasound (FAST/eFAST) to look for air or blood around the lungs and heart
• Chest X-ray to show a collapsed lung, blood in the chest or retained fragments
• CT scan in stable patients to map the wound track and organ injuries
• Blood tests, blood type and crossmatch for transfusion

Treatment

Emergency treatment

• Oxygen and, if needed, a breathing tube and ventilation.
• A three-sided or vented dressing applied by paramedics or ER staff as a temporary measure.
• Needle decompression or finger thoracostomy to release a tension pneumothorax.
• Chest tube (tube thoracostomy): a tube placed between the ribs, away from the wound, drains air and blood and lets the lung re-expand. This is the definitive treatment for most open pneumothoraces.
• Blood transfusion and control of bleeding.

Surgery

About 15 in 100 penetrating chest injuries need an operation (thoracotomy or video-assisted surgery), for example for:

• heavy or continuing blood loss through the chest tube
• injury to the heart, great vessels, airway or esophagus
• a diaphragm tear or abdominal organ injury

Wound care

Once the chest is drained and stable, the skin wound is cleaned, any debris removed, and closed or left to heal. A tetanus booster is given if needed, and antibiotics may be used for contaminated wounds.

Recovery and complications

Many people with an isolated chest wound treated with a chest tube go home within a few days. Possible complications include:

• infection of the chest cavity (empyema) or the wound
• a retained blood clot in the chest that needs a second procedure
• pneumonia and persistent air leak
• chronic pain at the wound or where the chest tube was placed

Recovery after surgery to the chest takes several weeks. Avoid heavy lifting until your surgeon says it is safe, and seek help for fever, increasing breathlessness or wound redness.

Frequently asked questions

What do bubbles around an open chest wound mean?

Bubbles or frothy blood mean air is moving in and out of the chest through the wound. This is an open pneumothorax, also called a sucking chest wound. The lung on that side is collapsing. Call 911 or your local emergency number immediately.

Should you cover a sucking chest wound?

Current first aid guidelines for untrained bystanders advise leaving the wound open or using only a loose, non-airtight dressing while pressing to control bleeding. An airtight cover can trap air and cause a tension pneumothorax. Trained responders may use a vented chest seal.

What is the treatment for an open chest wound?

In the hospital, doctors give oxygen, insert a chest tube to drain air and blood so the lung re-expands, replace lost blood and close the wound. Surgery is needed if the heart, major vessels, lung or diaphragm are seriously damaged.

Can you survive an open chest wound?

Yes. Most people who reach a trauma center alive survive. Outcome depends on what was injured inside. Wounds that only cause a collapsed lung often need just a chest tube. Injuries to the heart or major blood vessels are much more dangerous.

Should I remove an object stuck in the chest?

No. Leave it in place and pad around it to keep it still. The object may be plugging a damaged blood vessel, and removing it can cause severe bleeding. Surgeons remove it in the operating room.