Self Defense Medicine Session 9: Chest Seals

Now I wonna talk about chest injuries specifically penetrating chest injuries. And we're talking about, when we say thoracic region or the chest, we're not talking about the entire torso of the human body, we're actually talking about anywhere there's ribs, okay. So, for at this level all we're concerned about is anything that goes if we get gunshot wounds or stab wounds, or anything that penetrates past through the ribs, in the torso, the thoracic region, all right. Now, we've got kind of a makeshift sketch here, okay. And we're gonna talk and kind of lay out some anatomy pieces for you and the physiology of what's going on with healthy, and then talk about what happens when it's unhealthy, or there's an injury.

And then we're gonna talk about how some of the things that we can do to actually solve those problems to make it a little bit easier and keep our patient breathing and alive until the ambulance arise, or they get make it back to the ER. So, starting right off, we've got a the trachea or the windpipe, okay. And it's this tube that comes down the front of your throat there in front of your neck, okay. Now, think of it as like kind of a garden hose, not necessarily same material, but it's about the same size, maybe a little bit bigger, okay. And actually air the way it gets in your body is actually enters through either your nose or your mouth.

Now, you can't do both at the same time. And now you're gonna try at home, it's okay. You're gonna make this snorting kind of a sound, but there's this flap in the back of your mouth in the top of your throat actually prevents that from, you getting air either in through your nose and your mouth at the same time. And it will explain how important that is in a little bit. But air goes, enters that nose or mouth, goes down inside this wind pipe or your trachea, and then it branches off into your bronchial stems and then you've got the lungs.

You've got the patients right lung and the patient's left lung. And then in the middle, we've actually got the heart that sits kind of just a little offset, something about like that. Now, obviously this isn't to scale and everything, I make a much better medic than I do artists, but around each lung is this small little sac that lines the lung in the outside of the lung, okay. And each lung has its independent little sac and that's a called a pleural sac, okay. And it rides right up through there.

And then also underneath here, we've got this large flat muscle, okay. That's called the diaphragm, okay. And that's the primary muscle that allows us to breathe. So, when you inhale, that diaphragm sits right underneath your rib cage, expands down and sucks down and sucks the air through your nose or your mouth, down the wind pipe or your trachea into your left and your right Now, as that diaphragm, as that muscle pulls down, well, our lungs expand and you feel, you think, oh, I've got that muscle tissue between the ribs, well, the intercostal space, or that muscle tissue between the ribs. That helps some, but it's, and it helps some, one of you exhale and constricting and pulling back the lungs and the chest wall.

So, it flexes. So, around here, we've got our ribs across there. Healthy lungs, the air goes through here, down inside the lungs, magic happens and the oxygen is now, the blood is now picking up the oxygen and it circulates through the heart, circulates through the body, okay. And that happens about 12 to 15 times a minute, all right, for healthy. Now, we're talking about a violent altercation.

So, maybe it's a stab wound, or perhaps maybe it's a gunshot wound. Well, what happens is now we've get this hole through the chest wall, okay. So, let's say over here on the side here, our patient here takes, has a gunshot wound that actually creates this hole here. So, we've got this hole now that's, and this also there's a hole into the long, all right. Now, air is gonna flow, well, let me back up.

Think of your lungs. It is actually a positive, negative pressure system, okay, inside this whole thoracic region here and it's all pressurized. So, one of your lungs inhale, okay. They expand, all right, and they're very fragile. Back to that pleural sac that was around here.

All that pleural sac does is act as a lubricant, okay. Even as smooth as ribs are on the inside, maybe you've gotten a slab of ribs, beef or pork ribs out of the grocery store in the inside it's really smooth. Well, just even as smooth as that is, would tear up our lung tissue and only a matter of few moments, or a few breaths without that sac around there, okay. So, it's very important to have that pleural sac. But that, if that bullet has come into the one, and let's not necessarily talk about an exit wound just yet, but it's come through the skin, through the chest wall into the lung, now we have a hole here and here in the lungs.

What happen is that air flows, follows the path of least resistance. Well, air can be sucked in because now this diaphragm is trying to inhale. You'll suck in air through here. Also, as air is coming through your mouth, your nose and down your trachea, that wind pipe into your lung, it's also being pulled out of there as well. So, that creates a pnemothorax, or a sucking chest wound.

Hence the name sucking chest wound because well, it makes a sucking sound. It'll make this, kind of this type of sound, okay. Well, that's one indicator that that's what's going on. That you can help when you're doing your assessment as you hear, you can actually you hear that sound. So, first off, we've got to figure out, hey, well, we've got this hole here.

That's bad because what's gonna start happening is air, this space here is gonna start filling up and the lung tissue is very, very fragile, okay. Well, something's got to give. And the air, that one lung there is gonna start getting compressed and it's gonna start getting crushed by all the pressure built up over here on this side. Some of the pressure is gonna be built over here too, but it's probably gonna be here over the weaker side, over the weaker lung and that lung instead of it being as nice symmetrical oval shaped and that pink frothy sponge, it's actually started deteriorating, getting crunched up and shrink up, okay. And obviously that's gonna cause the patient to experience difficulty breathing, shortness of breath.

Well, before that happens, one of the clues is, hey, will they have a hole in their chest? So, we've got to deal with this first, this hole. Simple fix for that is we use a chest seal. Now, earlier we talked about with the OLAES dressing, we talked about in the inside, they actually have that sheet of plastic in there, right? Now that is an option and we can use it as a, if we absolutely have to and that's all we've got with us.

And the idea with this is any chest seal, regardless we're using this one, or some of the others I'm about to show you, it's we need to make that seal on top of that skin, airtight and watertight. Meaning no air can go in or out. Same thing, we don't want any fluids or water being able to go in and out of there as well. That's gonna buy us a little bit of time. That's the idea using this plastic sheet, is we can actually take this and apply it.

For example, if this star on my shirt is actually the hole, well, then I would simply apply this and try to make it as airtight and watertight as I possibly could. It's gonna be a little difficult. I'm either gonna hold this, or take that OLAES bandage and wrap it around there as tight as I can. That's gonna be very, very difficult to do to keep that airtight, watertight. Another option though are the HALO Chest Seals, okay.

Now, these are occlusive dressings meaning they don't allow any air to go through back and forth, all right. And inside the Halo Chest Seals are packaged, there actually comes two because where you have an entrance wound, you might have an exit wound. So, we've got two chest seals here and all they are is just giant stickers. If you'll notice, it's just a giant sticker. We've got this tab here we can pull away.

And you'll notice it's kind of got this gel like substance on there, okay. The gel is there to actually mold to the skin and help create the airtight, watertight seal over hair follicles, folds in the skin, wherever it may be around the arm, underarm area, or a breast or something to that extent. So, allows for some of those creases in the skin, also for those hair follicles, okay. And it's super, super sticky stuff. So, this is designed, if it's the patient is sweaty or bloody or muddy, it'll still stick to them, okay.

So, all we'll do is simply peel that off and stick it onto there right directly over that hole and create that airtight, watertight seal. Now, what's gonna happen is now we've, so we've taken this and now we've created that seal. We put that halo seal on there and we've got an airtight, watertight seal on that end but we still have the hole inside on the lung. Well, the only way we can do that is with surgery and we leave it up to the surgeons in the OR to take care of that. At level, there's not much we can do for that.

However, with this sealed up here, we still have air coming down the windpipe, the trachea into the lung, out of the lung into this space here. Well, that can become a problem. How do we eliminate some of that pressure? On our Halo Seal, we've still got that, that tab there, okay. We simply, when, after you apply this on there, the patient starts breathing somewhat more normal than they already were with a hole in their chest.

And as they're breathing, they'll start having more difficulty breathing. They'll say, "Okay, it's starting to hurt to breathe now." They'll take shorter breaths, maybe more rapid. Well, then all we have to do is simply peel that tab and peel back far enough to allow the air to escape back through that hole that's already there. So, air will then escape through it and then we simply just reseal it back up over it. We'll give him a couple of breaths, the air will escape out and seal it back over.

Well, that's great. Well, what if we have the entrance and the exit wound? Let's say they were, they received stab wound, or a gunshot wound to the front of their chest and the exit wound of the knife, the worst case scenario, or the gunshot wound. Well, then we've got to use two different chest seals. We can take the Halo Chest Seal, and I'd recommend putting it on the back so that when you roll the patient over and you're doing your blood crawl, if you see it, you slap that chest seal on there and then when you're rolling back over, we're gonna use a different, a little bit different type of chest seal.

We're gonna use what they call a non-occlusive dressing. One example is that as the Russell Chest Seal and they come packaged like this and there's a few different ones out there in the market. This happens to be one that I prefer. And when you open it up, you'll notice it's still kind of thick, it still got kind of a gel feel to it. But if you can look carefully, you'll see that this diamond or this square, depending on how you look at it, we've got this square here, but in the middle here, we've got a hole.

And then on all four corners, we've got these circles. What this allows is air to escape out, but not back in. So, now we've got, what we can do on that one hole is slapped this on top of that bullet hole. So, let's say again, the star is where my bullet hole is I'll simply peel this back, lay the center it on top of that hole and make sure it's tight and smooth. So, that way, whenever the pressure starts to build up, it technically burps itself.

And that's what we call it, if you don't have one with a valve, then you just simply just burp the chest seal, the occlusive dressing like the Halo, you simply burp it, peel it back and reseal it. Well, this one eliminates us having to do that. So, let's say you have a delayed response time for, say it's an active killer situation where, hey it's gonna take several minutes, 30 minutes, 45 minutes, maybe an hour or so for the ambulance to get cleared to be, for them to come into that scene. Well, then it's nice to have one of these chest seals that you can sit there and have them, that you can have, that we don't have to keep burping it and you can continue on getting them out, or helping others. So, we've got that chest seal on the back, the Halo Seal, and then on the front, we've got this one with a valve that allow it to breathe, okay.

But as far as this hole inside, there's not much we can do here. That is gonna be a surgical procedure that, in the surgery, that in the OR they can take care of that. So, if we've got penetrating chest trauma, meaning there's bullet holes, or stab wounds anywhere in the rib cage, now, don't forget the body is three-dimensional, we've got the front, the sides and the back, so, don't forget when you're doing your blood crawls, is where we check all the way around the total area of that chest, of the chest wall. We're looking and feeling for those bullet holes, or those stab wounds. If we do, the easy fix is a chest seal, either one, and then it'll either burp itself, or we'll have to sit there and burp it.

Students always ask, "Well, how often do you have to burp it?" Well, it's gonna vary. Every body is made up a little bit different and depending on who they are, what in shape, and all these other variables that come into play, you may or may not have to burp it so often. It may be every third breath. It may be every 30th breath. It all depends on the mechanism of injury and several other variables.

However, once you put the chest seal on there, you need to stay in contact with your patient and stay with them until help arrives, okay. Because it can also become, the patient's gonna be panicking. Think about it, if you're sitting there and you only got 50% of your lung capacity, that's gonna be a pretty stressful environment, let alone, you were just involved in a violent altercation. So, stayed with that person throughout and be sure you tell the paramedics and EMT, "Hey, this is the type of chest seal that we put on there." So, they will be able to help and continue on their treatment. So to recap, may seem like there's a lot going on here, but the idea is if there's any holes in the thoracic region, anywhere around the ribs, we need to get a chest seal on there as quickly as possible.

If you only have one and you're using something like the Russell Chest Seal with the, with non-inclusive, meaning it's got vent, then use that one. If you've got the Halo, or something that's occlusive where it's just airtight, watertight, that's just as fine. Just pay attention and you're probably gonna have to sit there and burp it every so often. One more thing about the lungs, don't forget they're also very, very vascular. So, if there's any penetrating trauma, or any blunt trauma for that matter as well, they may bleed.

Well, if the lungs are bleeding, that thoracic area is gonna end up filling up with blood as well. So, that's why we seal with airtight, watertight, but what happens when you start getting all that, the fluid and that blood coming out of that hole, okay, on the side of the chest wall and the skin, well, when blood reacts to the air, it becomes a clot. Inside your chest seals, you, some chest seals are prone to getting clogged with the vents, okay, the chest seals with vents, they're prone to getting clogged with those clots. So, the cool thing about this Russell Chest Seal is that it can actually peel this back, reach inside through there and manually pick out any clots, or move them, push them out of the way or what not to allow the vent to actually keep on working the way it's supposed to. So, don't forget, the lungs are also very, very vascular and can fill up with blood as well as air.

Now that you know how they work and what's going on with the anatomy portion of it and the physiology of it, of those thoracic injuries, Let's go and take a look at how we actually apply these to a patient. So, our threat's been neutralized and our patient here is having some difficulty breathing, but we're not entirely sure what's going on. We're gonna go ahead and perform the blood crawl, as we've already done it. I'm gonna start at the back of the head. Look, there's nothing there, here, back of the neck, nothing.

And I'm gonna check this side of the torso and then I check this side. And as I do, I notice, hey, there's something here. There's a hole here. So, I investigate this further. The easiest way to do that is to come up here, and see what we have.

And it looks like we've got some kind of chest wound here, some penetrating trauma inside the rib cage. So, best option for right now is to make this an airtight, watertight seal. We can take out our Halo Seal. Simply pull one of these stickers off and put it directly over this and try to smooth this out and get it as airtight watertight as we possibly can. We've got that.

Now, we need to check and make sure there's no further injuries on the back for as an exit. So, we'll roll the patient. We'll look. Nothing, nothing there. We'll roll them back.

So, that looks like it's our only wound. Looks like it's pretty airtight, watertight all the way around. We're gonna go ahead and continue our rest of our patient assessment. Feeling for anything abnormal. Any holes, or any crepitus, or any bones poking out.

Nothing there. So, I finished my assessment on the patient. I didn't find any other further injuries or illnesses. So, let's talk about this chest injury. What's going on in the body, when we get a gunshot wound to the chest or anywhere that thoracic region, meaning anywhere you have ribs in your rib cage?

There's a positive and negative pressure system. So, think of your chest wall, or your chest as the container and on the inside you have to sponge-like balloons, your left and right lung. What happens is that bullet enters through the chest wall, okay, the wall itself, creates a hole there, then it goes into the lung, and let's say, it just gets lodged in there. So, that bullets lodged somewhere in that lung. It's also created another hole in the lung tissue itself and lung tissue is very frothy, very vascular, very sexy, pink, spongy-like material.

It's also very fragile. So, we've got two holes technically. We've got one on the chest wall. We've got a whole also on the lung. Well, we can fix the hole on the chest wall simply by putting the chest seal on there, making it airtight, watertight as we've done.

Now, the problem is we've got this hole still inside the lung and it's leaking air. Every time we breathe in, our diaphragm expands, we take it breath in and the air goes down into our windpipe and down into our lungs and actually will leak out of that hole. So, when it leaks out of that hole, it builds up on pressure inside the chest wall. Now, that doesn't sound too bad until after a while it starts creating enough pressure on this, on the weaker lung, the one with the hole and the bullet in it. And it'll actually build up enough pressure and collapse that beautiful lung and will collapse and start making it harder and harder to breathe at the same time.

when that starts happening, it's gonna start pushing stuff over like the heart. And it's gonna start making the lungs, heart, the other lung, the healthy one, work twice as hard than it's normally supposed to, along with the heart's gonna accelerate a lot more and the patient's gonna have a hard time breathing. So, the only way we can fix that is through surgery which we can't do here, or with a chest tube which we're definitely not gonna do out here in the field. So, with that chest seal over the wall, we've solved that problem. To alleviate the problem of the tension pneumothorax that we developed now, and that's what it is, we've got the lung tissue being collapsed over here and all that pressure built up, we simply peel this up and burp it.

And it'll look like this. We'll simply peel this back and you'll hear air escape, you'll hear this, you'll hear the air escape and then you'll simply cover it back up and make sure it's airtight, watertight again. When you do that, the patient probably will look at you and thank you for that. They'll say, "Thank you." And they actually be able to breathe then. So, let them have a few good breaths, let the air escape, close it back up, make sure all the sides are taped up and you're good to go.

If you've got the Russell Chest Seal, or the one with the valve, then you don't have to burp it because it already has that one way valve that allows the air to burp. But the Halo Seal is a really good chest seal for that option. So, just to recap what we've done, we started doing the blood crawl. We found this injury here, the hole in the chest in the rib cage. So, immediately exposed the patient.

We identify, we deployed our Halo Seal, make sure it's airtight, watertight, and then continue the rest of our assessment. Now, some people may ask, "Well, if it's bleeding, "do we apply direct pressure "and put our hands over there, "gloved hand over the patient?" Well, not necessarily. Chest wounds may or may not bleed a lot, but we're not worried about the bleeding so much as we are the air escaping, or getting into it. So, get that chest seal on there, airtight, watertight, make sure it's on there nice and snug. The good thing, another thing about these Halo Chest Seals is no matter if the patient does have excessive blood, or sweaty or a lot of hair, that glue on there is really, really strong and really adhesive.

So, it'll still stick on there. You don't have to worry about shaving the patient first, or wiping bone dry. You can just keep on with what you got. And then don't forget to go ahead and finish your rest of your patient assessment.