Chest Seals in an MCI

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Chest Seals in an MCI

Do penetrating chest injuries in a mass casualty incident always need a chest seal? The clinical reality behind tension pneumothorax and rapid evacuation.

In an active shooter/MCI, should you use a chest seal to treat a gunshot wound to the chest? The answer is more nuanced than most training suggests.

Two Types of Chest Injury

An injury to the chest can be one of two problems: a breathing problem or a bleeding problem.

  • —Pneumothorax (breathing problem) — can be caused by a hole in the chest from a gunshot, or from a rib fracture after blunt trauma
  • —Massive hemorrhage (bleeding problem) — massive bleeding from the lung after an open chest injury from a gunshot

What a Chest Seal Does

The open injury and breathing problem is easily fixed with a chest seal and can be applied in the field. The closed pneumothorax is fixed in the hospital by making a hole, putting a chest tube in, and connecting it to suction.

The bleeding problem from a gunshot is far more concerning — there can be massive blood loss and it can only be fixed by a staple line across the lung injury in the operating room.

The Tension Pneumothorax Risk

So what if you seal the hole? The volume of blood can fill the chest cavity and push the heart and great vessels to the other side — "kinking" the vessels, preventing blood flow, dropping blood pressure, and reducing perfusion to the head and major organs.

This is the dreaded Tension Pneumothorax. To treat it and relieve the tension, you must open the hole (burp) that you sealed to release the pressure.

The Core Question

So why did you seal the hole in the first place? They need a surgeon in the operating room. They need rapid evacuation to a higher level of care.

In a mass casualty incident, the priority for penetrating chest trauma is rapid evacuation — not field treatment that may delay movement or create additional complications.

Chest seals remain a valid field intervention in many scenarios, but in a high-volume MCI, the calculus shifts toward speed of evacuation over complexity of treatment.

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