Chest Seals, Tension Pneumothorax, and What Really Matters







Chest Seals, Tension Pneumothorax, and What Really Matters

By Jonathan Willis 

Tension pneumothorax is one of the leading causes of preventable traumatic death in the United States. It sounds complex, but the concept—and what you need to do about it—doesn’t have to be.

In simple terms, a tension pneumothorax happens when air enters the chest through a hole in the chest wall and becomes trapped. With every breath, pressure builds inside the chest until the lungs can no longer expand and the heart can’t fill or pump effectively. When that happens, the patient will deteriorate quickly.

For lay responders, preventing that pressure buildup is the goal.


                    

What You Should and Should Not Do

Let’s clear up some confusion right away.

  • Needle decompression is not appropriate for lay responders.

  • Chest seals are.

A chest seal is the safest and most effective tool available to non-medical responders for managing penetrating chest trauma. If there’s a hole in the chest, seal it.

That’s the priority.

What Counts as a Chest Wound?

Any open injury to the chest wall should be sealed. That includes wounds on the:

  • Front of the chest

  • Back

  • Sides

A good rule of thumb: if the injury is between the collarbones and the lower ribs, it should be sealed.

Forget outdated teaching about wound size. If you see a hole—cover it.


                      

Vented vs. Non-Vented Chest Seals (and Why It Usually Doesn’t Matter)

People often ask whether they should carry a vented or non-vented chest seal. The short answer is:

It doesn’t matter nearly as much as people think.

There are two main types of commercial chest seals:

  • Non-vented (a simple occlusive seal)

  • Vented, which may use:

    • One-way valves, or

    • Laminar (channel-based) vents

While vented seals are designed to let air escape, studies have shown that:

  • One-way valve seals can clog with blood or tissue

  • Some vented seals fail to adhere reliably

  • Even advanced vented designs are not foolproof

No chest seal—vented or not—is a “set it and forget it” solution.

The Most Important Rule After Applying a Chest Seal

Apply the seal, then watch the patient.

That’s it.

Any patient with a sealed chest wound can still develop a tension pneumothorax. This is true whether the seal is vented, non-vented, commercial, or improvised.

Watch for:

  • Increasing difficulty breathing

  • Worsening anxiety or restlessness

  • Bluish lips or fingertips

  • Rapid heart rate

  • Deteriorating level of consciousness

If the patient gets worse after a seal is applied, the seal may need to be lifted briefly (“burped”) to release trapped air, then resealed. This is a simple maneuver that can be life-saving and is appropriate for trained lay responders.



Improvised Chest Seals Work

Before purpose-built chest seals were widely available, responders improvised—and it worked.

Effective improvised seals have included:

  • AED pads

  • Plastic packaging

  • Occlusive dressings taped on all sides

The body doesn’t care about branding.
It cares about whether air is entering the chest.

The Big Picture

Chest seal use has sometimes been overcomplicated. In the civilian environment, most responders are not dealing with prolonged evacuations or battlefield conditions. The priority is early intervention and ongoing observation.

Here’s what actually matters:

  1. Seal any open chest wound

  2. Monitor the patient

  3. Be ready to reassess and adjust

That’s it.

Final Takeaway

If you remember nothing else, remember this:

Place the chest seal. Watch the patient. Be ready to act again.

The specific seal you choose is far less important than using one promptly and understanding what to watch for afterward.

Trauma care isn’t black and white. It’s dynamic.
And saving lives often comes down to doing simple things well—at the right time.





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