Initial management of open pneumothorax

Pneumothorax is a thoracic and pulmonary abnormality that known as the accumulation of air within the pleural cavity, leading to mechanical disruption of respiratory cycles and in some circumstance, hemodynamic instability. Open pneumothorax is called as a ‘sucking’ chest wound also since the air can moves either inward and/or outward. Referring to the previous tactical combat casualty care (TCCC) guideline, the initial management of open pneumothorax relies on the application of a three-sided thoracic bandage that functions as a one-way valve that allows the air to leave but not entering the pleural cavity; however, several recommendations have been changing lately and reports regarding massive open pneumothorax is rarely reported. We hereby present a case of a 47-year-old male with open left pneumothorax and multiple rib fractures that experienced traffic accident episode prior to admission. Primary survey showed unremarkable results except for the wide thoracic open lesion at the left 4th-8th rib cage. Our patient immediately underwent exploratory thoracotomy, wound debridement, with emergency 4th-8th rib cage wiring and clipping and chest tube insertion. He did not experience any significant morbidity and no life threatening complications were recorded postoperatively; postoperative vital signs showed unremarkable results. The 10th edition of advanced trauma life support (ATLS) and TCCC guideline stated that sufficient three-sided dressing of the wound edges could prevent the respiratory deterioration seen in open pneumothorax cases, followed by chest tube insertion and surgical repair to treat the underlying thoracic cage abnormalities. Initial management of open pneumothorax in general are primary survey, adequate chest dressing, analgesics, and they all must be individualized with the patients’ condition. Adequate chest dressing might be not widely available especially for massive chest wound and in order to prevent the progression to pneumothorax. Chest tube insertion with definitive chest wall repair can improve the patients’ outcome. Open pneumothorax is one of the lethal thoracic lesion since it interrupts effective respiration. Primary survey, hemodynamic stabilization, adequate chest dressing - if available and chest tube insertion followed by definitive wall repair can prevent the development of tension pneumothorax and mortality.