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Three Part Question

In [a patient with a penetrating chest wound] is [a three sided dressing or a one way chest seal] better at [prevention of respiratory complications]?

Clinical Scenario

You are providing on site medical cover at a large music festival. There has been an incident and a 26 year old man is brought to the medical tent after being stabbed. He has a sucking chest wound. Should you use the fancy chest seal device in the medical box or make your own three sided dressing while you wait for the ambulance to arrive?

Search Strategy

Medline 1950 to Jan 2011 using OVID interface.
(penetrating OR open OR sucking OR pneumothorax OR wound) AND (chest OR thoracic OR thor$) AND (dressing OR seal$ OR occlude$)
Search terms "asherman" and "bolin" were also used.

Search Outcome

Altogether 1116 papers were identified. Five papers seemed relevant to the question: one animal study, two guidelines and two case reports.

Searches of EMBASE, CINAHL and the Cochrane Library produced no new evidence.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hodgetts et al. 1999 England	Battle field casualties with sucking chest wounds.	Battlefield First Aid training.	Replacement of a three sided dressing with Asherman Chest Seal		The advice is based on the practical problems of using adhesive dressings to fashion a three-sided dressing.
Lee et al. 2007 England	Open pneumothorax	The prehospital management of chest injuries: a consensus statement.	Optimum treatment is the application of an Asherman Chest Seal		No evidence cited
Arnaud et al. 2008 USA	Standardised open pneumothorax model in 30kg Yorkshire swine (n=16) block randomised to receive either an Asherman or a Bolin chest seal dressing.		Air injection into thoracic cavity to cause 15-20% MAP reduction	372 (SD 214) ml	Porcine skin, while similar to human skin, may have different adherence characteristics. The open pneumothorax model remains reliably open and so allows the seal to "work" and so prevent a tension pneumothorax. A real wound with major haemorrhage could seal itself and allow a tension pneumothorax to develop.
			Volume air injection (no blood in thoracic cavity) with no MAP reduction or HR increase	1500ml for both seals
			Volume air injection (after 240ml injection of blood in thoracic cavity) with no MAP reduction or HR increase	1500ml for both seals
			Seal adherence to dry skin (scale 0-3)	Asherman 2.8 (SD 0.6) vs Bolin 2.6 (SD 0.8), P=0.55
			Seal adherence to skin soiled with blood (scale 0-3)	Asherman 0.4 (SD 0.7) vs Bolin 2.7 (SD 0.7), P<0.001

Comment(s)

There are no studies which directly compare the use of three sided dressings and one way chest seals in the management of open chest injuries. Battlefield medicine would provide the most likely place for us to learn more regarding this type of injury and initial management, however, research trials are difficult to carry out in this environment. Asherman chest seals have been used to stabilise needle thoracocentesis cannulae in the pre-hospital setting (Allison et al.) and to treat postoperative air-leaks after thoracic surgery (Rathinam and Steyn). In the latter series of six cases Asherman seals were used after chest drains fell out. In all cases lung expansion and cessation of the air-leak was seen without the need for a further chest drain. Both the Asherman and the Bolin chest seals appear from the animal study to do the job but the Bolin may have the advantage in terms of adherence.

Editor Comment

HR, heart rate; MAP, mean arterial pressure.

Clinical Bottom Line

There is no clear evidence to suggest that the use of one way chest seals would reduce the incidence of respiratory complications in patients with penetrating chest wounds. However, these seals may be easier to use and should be considered as part of the medical kit for out-of-hospital settings.

References

1. Hodgetts TJ, Hanlan CG, Newey CG. Battlefield First Aid: a simple, systematic approach for every soldier. J R Army Med Corps. 1999;145:55-59.
2. Lee C, Revell M, Porter K, et al. The prehospital management of chest injuries: a consensus statement. Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh.Emergency Medicine Journal. 2007;24:220-224.
3. Arnaud F, Tomori T, Teranishi K, et al. Evaluation of chest seal performance in a swine model: comparison of Asherman vs. Bolin seal Injury 2008;39(9):1082-8.
4. Allison K, Porter KM, Mason AM. Use of the Asherman chest seal as a stabilisation device for needle thoracostomy. EMJ 2002;19:590-591.
5. Rathinam S, Steyn R. Management of complicated postoperative air-leak - a new indication for the Asherman chest seal. Interactive Cardiovascular & Thoracic Surgery 2007;6(6):691-4.