Open chest wounds come in a variety of shapes and sizes. Their one commonality is an open communication between the pleural space and the external environment. The wounds have often been sealed by the soft tissues of the chest wall in the vast majority of patients with penetrating injuries to the chest. The primary concern with these patients is the diagnosis and treatment of underlying thoracic, cervical, and/or abdominal injuries. Rarely, small perforations may produce a valve-like entry into the pleural space, enabling air to be “sucked in” during inspiration but blocking air egress during expiration.1-3 Thus air will continue to accumulate, leading to a tension pneumothorax requiring needle decompression followed by a tube thoracostomy. Larger, more destructive wounds of the chest may also occur. These are most common in combat injuries. In civilian practice, they are often secondary to shotgun injuries. The larger wounds are also caused by high-velocity weapons, explosions, on-the-job injuries, propeller injuries, or fencepost impalements, to name a few. Clothing, wadding, shell fragments, and pieces of the chest wall may all be driven into the thoracic cavity. Such injuries are associated with physical loss of a portion of the chest wall itself, making adequate ventilation impossible.4,5
These wounds are known by numerous names including open chest wounds, open pneumothoraces, sucking chest wounds, and communicating pneumothoraces. These specific open chest wounds are the focus of this chapter.
Wounds of the chest are described in the earliest of medical documents, the Edwin Smith papyrus. This document dates from the time of Imhotep (3000 B.C.). During Greco-Roman times, open chest wounds were universally fatal. Galen cared for chest wounds in gladiators. Treatment consisted of a poultice and leaving the wound open. This treatment did not change until the time of Theodoric in 1267 who advised the closing of chest wounds.
Techniques for managing chest wounds have improved with each subsequent war. The most important treatable aspect of these chest wounds was the associated open pneumothorax. The question of whether to manage such injuries open or closed remained controversial. John de Vigo, in 1514, was the first surgeon to present his views on gunshot wounds of the chest. He thought them to be universally fatal and, for the most part, untreatable. William Hewson, in 1767, observed that a patient with a large open chest wound was not able to breathe but could do so easily once the injury was closed. It took another 40 years for Baron Larrey, Napoleon’s Surgeon, to confirm Hewson’s observation in a wounded soldier. Another famous accounting of an open chest wound was by William Beaumont in 1825. He arrived within one-half hour of the injury and saved the patient’s life by closing his chest wound.
By the final years of World War I, the controversy of “to close or not to close” was resolved in favor of immediate wound ...