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. 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.1 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.). It contains descriptions of 58 cases, three of which involved chest injuries per se. One was actually an open chest wound, case number 40. The patient sustained a penetrating injury to the anterior thorax through the manubrium. Treatment consisted of binding the wound with fresh meat on the first day and, later, with grease, honey, and lint.
During Greco-Roman times, open chest wounds were universally fatal. In 362 B.C., Epaminondas was wounded by a spear to the chest at the battle of Mantinea. Once he discovered that the Thebans had been victorious, he pulled the spear out, knowing that he would die.
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, who advised the closing of chest wounds. In 1267, he was quoted as saying, “The stitches should be placed in accordance with the size of the wound so that the natural heat cannot escape in any way nor the air outside be able to enter.” His advice was not accepted by all. The Master Military Surgeon Paré left these wounds open for 2 to 3 days to allow drainage of blood, after which he would close them.
During the Battle of Crecy in 1346, firearms and firearm injuries were first introduced. In 1382, small guns were used ...