A chest seal is a specialized occlusive dressing used to treat penetrating chest wounds, often called “sucking chest wounds,” which compromise the integrity of the chest wall. These injuries allow air to be drawn into the pleural space outside of the lung, potentially leading to a collapsed lung, known as a pneumothorax. Applying a chest seal creates a barrier that prevents outside air from entering the chest cavity through the wound. This seal must sometimes be temporarily lifted, a process called “burping,” to relieve a dangerous buildup of trapped air. This burping technique is an emergency procedure necessary when a chest seal, particularly a non-vented one, fails to release air that has leaked from the injured lung tissue.
Identifying the Signs of Tension Pneumothorax
The need to burp a chest seal arises from the development of a tension pneumothorax, a serious condition where air accumulates in the chest cavity under increasing pressure. If air enters the pleural space but cannot escape, this pressure collapses the lung on the injured side and pushes the mediastinum—the structure containing the heart and major blood vessels—toward the opposite side of the chest. This shift severely restricts the heart’s ability to fill with blood and compresses the uninjured lung, leading to rapid circulatory and respiratory failure.
Recognizing the signs of this pressure buildup is paramount before intervening. The patient will exhibit increasing respiratory distress, such as severe shortness of breath or progressively rapid breathing, despite the chest seal being in place. Systemic signs of shock will also appear, including a fast heart rate (tachycardia) and a noticeable drop in blood pressure (hypotension).
Other physical indications include jugular venous distention (distended neck veins), which results from the pressure inhibiting blood return to the heart. Tracheal deviation, where the windpipe shifts away from the injured side, is a very late sign. When these symptoms worsen after a chest seal application, it strongly suggests a failing seal or an underlying air leak is causing a life-threatening tension pneumothorax.
Preparing for the Burp Procedure
Before attempting to burp the chest seal, the patient’s position and the seal’s condition must be quickly assessed to maximize the procedure’s effectiveness. Ideally, the patient should be placed in a semi-reclined or sitting position if they are conscious and able to tolerate it, as gravity can assist in the upward escape of trapped air. If the patient is unconscious or has other serious injuries, the semi-reclined position is often preferred for decompression.
The rescuer must quickly confirm the type of chest seal in use, as non-vented seals are more prone to requiring burping than modern vented seals. Even vented seals can become clogged with blood or debris, necessitating the same decompression technique. Visually inspect the seal’s edges to determine which part is best situated for a brief lift, typically the edge closest to the ground or the lowest point of the dressing.
Executing the Chest Seal Burp
The burping technique involves briefly breaking the adhesive seal to allow the pressurized air to escape, acting as a temporary one-way valve. The rescuer should identify the edge of the seal that is easiest to access, often the one pointing toward the patient’s feet or the lowest part of the seal. The timing of the lift is important, as the procedure should be performed during the patient’s exhalation cycle.
As the patient breathes out, the positive pressure inside the chest cavity is highest, which aids in pushing the trapped air out. Gently lift just a corner or edge of the dressing, enough to break the airtight seal without peeling the entire patch off the skin. A distinct rush or whoosh of air should be audible as the accumulated pressure is released from the pleural space.
The seal should only be lifted for a moment, allowing the pressurized air to escape, and then immediately pressed firmly back down onto the skin. The goal is to restore the occlusive dressing’s function as quickly as possible, ensuring that outside air cannot be sucked back into the chest cavity during the patient’s next inhalation. If a significant amount of blood or debris is obstructing the seal or the wound itself, quickly wipe it away before reapplying the dressing.
Post-Procedure Monitoring and Assessment
Following the decompression of the tension pneumothorax, immediate reassessment of the patient’s condition is necessary to confirm the intervention was successful. The most immediate sign of relief is a reduction in the patient’s respiratory distress, with breathing becoming less labored and less rapid. The rescuer should also monitor for improvements in the systemic signs of shock, such as a slowing of the heart rate and a stabilized or rising blood pressure.
After the air is released and the chest seal is firmly reapplied, the patient must be continuously monitored for any recurrence of tension. A tension pneumothorax can redevelop if the underlying air leak from the injured lung persists and the seal becomes occluded again. If the signs of tension—like increasing difficulty breathing and dropping blood pressure—return, the burping procedure must be repeated immediately.
Continuous observation is required until the patient receives definitive medical care, as the burping procedure is only a temporary, field expedient measure. If repeating the burp procedure does not provide sustained relief or if the patient’s condition continues to deteriorate, further medical intervention, such as needle decompression, may be necessary. The goal is to stabilize the patient until they can be transferred to a facility for a chest tube insertion.