Open Wound of the Chest

Overview

Open wounds of the chest encompass a spectrum of injuries from minor surface lacerations to severe penetrating trauma that breaches the thoracic cavity. The chest houses vital organs including the heart, lungs, and major blood vessels, making any breach of the chest wall potentially life-threatening. These injuries can result from various mechanisms including stab wounds, gunshot wounds, motor vehicle accidents, falls, or industrial accidents.

The severity of an open chest wound depends on multiple factors: the depth of penetration, the location on the chest wall, the mechanism of injury, and whether vital structures are involved. Even seemingly minor chest wounds can have serious underlying damage, as the force of impact may cause internal injuries without obvious external signs. The unique anatomy of the chest, with its protective rib cage and the negative pressure system required for breathing, means that any breach can have immediate and severe consequences.

Chest trauma accounts for approximately 25% of all trauma-related deaths, with open chest wounds representing a significant portion of these cases. The mortality rate varies widely depending on the mechanism and severity, ranging from less than 1% for simple chest wall lacerations to over 50% for wounds involving the heart or great vessels. Rapid assessment, appropriate first aid, and immediate medical intervention are critical factors in improving outcomes.

Symptoms

The symptoms of an open chest wound vary significantly based on the severity, location, and structures involved. Recognition of these symptoms is crucial for appropriate triage and emergency management.

Immediate Visual Signs

• Visible wound or laceration on the chest wall
• Bleeding from the wound site (may be minimal with small punctures)
• Sucking sound with breathing (sucking chest wound)
• Bubbling of blood at the wound site during breathing
• Visible impaled object (never remove in field)

Pain and Discomfort

• Sharp chest pain - often severe and worsening with breathing
• Pain radiating to the back or shoulder
• Tenderness around the wound site
• Pain with movement or coughing

Respiratory Symptoms

• Difficulty breathing or shortness of breath
• Rapid, shallow breathing
• Inability to take a deep breath
• Coughing (may produce blood)
• Feeling of suffocation or air hunger

Signs of Complications

• Pneumothorax: Decreased breath sounds, respiratory distress, chest asymmetry
• Hemothorax: Shock symptoms, pale skin, rapid pulse
• Tension pneumothorax: Severe distress, deviated trachea, distended neck veins
• Cardiac tamponade: Muffled heart sounds, low blood pressure, distended neck veins

Systemic Symptoms

• Rapid heart rate (tachycardia)
• Low blood pressure (hypotension)
• Cold, clammy skin
• Confusion or altered mental status
• Extreme anxiety or sense of impending doom
• Loss of consciousness

Associated Risk Factors

Certain behaviors increase risk of chest wounds:

• Drug abuse - associated with increased violence and accidents
• Gang involvement or violent lifestyle
• Occupational hazards (construction, law enforcement)
• High-risk recreational activities

Causes

Open chest wounds result from various mechanisms of trauma, each with distinct characteristics and implications for treatment. Understanding the cause helps predict potential complications and guide management strategies.

Penetrating Trauma

Stab Wounds

• Most common cause in urban settings
• Usually low-velocity injuries with predictable wound tracks
• Depth depends on weapon length and force applied
• May cause pneumothorax, hemothorax, or cardiac injury

Gunshot Wounds

• High-velocity injuries with unpredictable paths
• Cavitation effect causes damage beyond bullet track
• May have entrance and exit wounds
• Often involve multiple organs
• Associated with higher mortality rates

Blunt Trauma with Open Wounds

• Motor vehicle accidents: Dashboard injuries, ejection, rollover
• Falls from height: Landing on sharp objects or surfaces
• Crush injuries: Industrial accidents, building collapses
• Blast injuries: Shrapnel and debris causing penetration

Impalement Injuries

• Falls onto sharp objects (fence posts, rebar)
• Industrial accidents with machinery
• Motor vehicle accidents with intrusion
• Object typically remains in place, stabilizing wound

Iatrogenic Causes

• Complications from medical procedures
• Central line placement
• Thoracentesis or chest tube insertion
• Post-surgical wound dehiscence

Risk Factors

Several factors increase the likelihood of sustaining an open chest wound or experiencing complications from such injuries.

Environmental Risk Factors

• Urban violence: Higher rates in areas with gun violence
• Occupation hazards:
  • Law enforcement and military personnel
  • Construction and industrial workers
  • Emergency responders
• Transportation: Motorcycle riders, bicyclists without protection

Behavioral Risk Factors

• Substance abuse leading to impaired judgment
• Gang involvement or criminal activity
• Domestic violence situations
• High-risk recreational activities without proper safety equipment
• Previous history of trauma or violence

Factors Affecting Severity

• Age: Very young and elderly have worse outcomes
• Pre-existing conditions:
  • Chronic lung disease
  • Heart disease
  • Bleeding disorders
  • Immunosuppression
• Delayed treatment: Rural location, lack of immediate care
• Multiple injuries: Polytrauma patients have higher mortality

Diagnosis

Diagnosis of open chest wounds begins with immediate visual assessment and progresses through systematic evaluation to identify all injuries and complications. The approach follows trauma protocols with emphasis on identifying life-threatening conditions.

Primary Survey (ATLS Protocol)

• Airway: Ensure patent airway, protect cervical spine
• Breathing: Assess respiratory effort, chest wall movement
• Circulation: Control hemorrhage, assess perfusion
• Disability: Neurological assessment
• Exposure: Full body examination for other injuries

Physical Examination

• Inspection:
  • Location, size, and depth of wound
  • Active bleeding or air leak
  • Chest wall movement and symmetry
  • Signs of subcutaneous emphysema
• Palpation:
  • Crepitus (subcutaneous air)
  • Rib fractures or instability
  • Tracheal position
• Auscultation:
  • Breath sounds (decreased or absent)
  • Heart sounds (muffled in tamponade)

Imaging Studies

Chest X-ray (Immediate)

• Pneumothorax or hemothorax
• Mediastinal widening
• Foreign bodies or projectiles
• Rib fractures
• Diaphragm elevation

CT Scan (When Stable)

• Detailed assessment of wound tract
• Organ injuries (lung, heart, vessels)
• Occult pneumothorax
• Vascular injuries requiring intervention

FAST Exam (Focused Assessment with Sonography)

• Pericardial fluid (tamponade)
• Pleural fluid (hemothorax)
• Abdominal fluid (associated injuries)

Laboratory Tests

• Complete blood count (assess blood loss)
• Type and crossmatch (prepare for transfusion)
• Arterial blood gas (respiratory function)
• Coagulation studies
• Troponin (if cardiac injury suspected)

Treatment Options

Treatment of open chest wounds requires a systematic approach prioritizing life-threatening injuries while preventing complications. Management ranges from simple wound care to complex surgical interventions depending on severity and structures involved.

Immediate First Aid

• Call 911 immediately
• For sucking chest wounds:
  • Apply occlusive dressing taped on three sides
  • Allows air escape but prevents air entry
  • Commercial chest seals available
• For impaled objects:
  • Do NOT remove the object
  • Stabilize with bulky dressings
  • Secure to prevent movement
• Control bleeding: Direct pressure around (not on) wound
• Position: Semi-upright if conscious and breathing

Emergency Department Management

Resuscitation

• High-flow oxygen or intubation as needed
• IV access and fluid resuscitation
• Blood products for hemorrhagic shock
• Pain management with careful monitoring

Chest Tube Insertion

• Indicated for pneumothorax or hemothorax
• Usually placed in 4th or 5th intercostal space
• Connected to water seal drainage
• Monitor output and air leak

Surgical Interventions

Emergency Thoracotomy

• Indicated for:
  • Cardiac tamponade
  • Massive hemothorax (>1500mL initially or >200mL/hr)
  • Major vascular injury
  • Loss of vital signs in trauma bay

Video-Assisted Thoracoscopic Surgery (VATS)

• Minimally invasive approach when stable
• Evacuation of retained hemothorax
• Repair of diaphragm injuries
• Control of ongoing bleeding

Wound Management

• Debridement: Remove devitalized tissue
• Irrigation: Copious saline irrigation
• Closure:
  • Primary closure for clean wounds
  • Delayed closure for contaminated wounds
  • May require muscle flaps for large defects

Medical Management

• Antibiotics:
  • Broad-spectrum coverage initially
  • Typically cefazolin plus gentamicin
  • Add anaerobic coverage for contaminated wounds
• Tetanus prophylaxis: Update as needed
• Pain control: Multimodal approach
• Respiratory support: Incentive spirometry, pulmonary hygiene

Rehabilitation

• Early mobilization when stable
• Respiratory therapy to prevent pneumonia
• Physical therapy for chest wall mobility
• Psychological support for trauma recovery

Prevention

While not all chest injuries can be prevented, many measures can significantly reduce the risk of open chest wounds and minimize severity when injuries do occur.

Personal Safety Measures

• Violence prevention:
  • Avoid high-crime areas when possible
  • Conflict resolution without violence
  • Domestic violence resources and support
• Substance abuse prevention:
  • Avoid drug abuse and excessive alcohol
  • Seek treatment for addiction
  • Designated drivers to prevent accidents

Occupational Safety

• Proper personal protective equipment (PPE)
• Follow workplace safety protocols
• Regular safety training and updates
• Report unsafe conditions immediately
• Machine guards and safety devices

Transportation Safety

• Always wear seatbelts
• Proper use of airbags
• Motorcycle protective gear including chest protection
• Bicycle helmets and protective clothing
• Defensive driving techniques

Home and Recreation Safety

• Secure storage of sharp tools and objects
• Proper handling of firearms
• Safety equipment for sports activities
• Fall prevention measures
• Child-proofing dangerous areas

When to See a Doctor

Call 911 IMMEDIATELY for any chest wound, especially if:

• Any penetrating injury to the chest
• Difficulty breathing or shortness of breath
• Sucking or bubbling wound
• Impaled object in chest (do not remove)
• Severe sharp chest pain
• Coughing up blood
• Signs of shock (pale, cold, rapid pulse)
• Loss of consciousness

While waiting for emergency services:

• Keep the person as still as possible
• Apply appropriate first aid as described above
• Monitor breathing and consciousness
• Be prepared to perform CPR if needed
• Keep the person warm

Post-treatment follow-up needed for:

• Wound check and dressing changes
• Signs of infection (fever, increased pain, drainage)
• Difficulty breathing developing after discharge
• Chest tube management if in place
• Suture or staple removal

Related Conditions

• Pneumothorax
• Hemothorax
• Rib Fracture
• Cardiac Tamponade
• Traumatic Diaphragm Injury
• Chest Wall Injury

References

1. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. American College of Surgeons; 2018.
2. Karmy-Jones R, Jurkovich GJ. Blunt chest trauma. Curr Probl Surg. 2004;41(3):211-380.
3. Mowery NT, Gunter OL, Collier BR, et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011;70(2):510-518.
4. Dennis BM, Bellister SA, Guillamondegui OD. Thoracic Trauma. Surg Clin North Am. 2017;97(5):1047-1064.
5. Broderick SR. Hemothorax: Etiology, diagnosis, and management. Thorac Surg Clin. 2013;23(1):89-96.
6. National Trauma Data Bank. Annual Report 2022. American College of Surgeons; 2023.