Asian Journal of Surgery xxx (xxxx) xxx

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Asian Journal of Surgery

journal homepage: www.e-asianjournalsurgery.com

Original Article

An expandable one-way-valve device for chest wound treatment:

Evaluation of open pneumothorax in a canine model
Weijin Yang a, 1, Youxu Zhou b, 1, Jianshen Qiu c, Chaochao Tao d, Weihang Wu a, Nan Lin a,
Chao Yang c, Ji Zhang c, Hongwen Zhang c, *, Yu Wang a, **
a
Department of General Surgery, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China
b
Department of General Surgery, The Third Affiliated Hospital of Fujian Traditional Chinese Medical University, Fuzhou, Fujian, China
c
Interventional Ward, Department of Medical Imaging, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian,
China
d
Department of Radiology, 900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, China

a r t i c l e i n f o a b s t r a c t

Article history: Background/objective: Thoracic injuries commonly occur after blunt or penetrating trauma, leading to a
Received 17 October 2019 blowing wound. For thoracic damage control in emergency, we evaluated a novel chest wound treatment
Accepted 20 October 2019 device manufactured using expandable material with a one-way valve, and compared it with closed
Available online xxx
thoracic drainage for first-line treatment of traumatic pneumothorax in a canine model.
Methods: Twenty beagle dogs (10 males and 10 females) were randomly and equally divided into two
Keywords:
groups. After arteriovenous catheterization, an open pneumothorax model was established in the beagle
Expandable device
dog using a minimally invasive procedure. The experimental group was treated using our test device,
Pneumothorax
Trauma
while the control group was treated by closed thoracic drainage. Animal survival, oxygen saturation
(SO2), oxygen pressure (PO2), and changes in chest radiograph with reference to open pneumothorax
before and after intervention were recorded at 30, 60, and 120 min.
Results: After a 24-h experimental period, all animals survived. The control group recovered more
quickly than the experimental group at 30 min post-trauma. However, the indices were close to normal
120 min after the test device was inserted. During the puncture, chest-wall hemorrhage was stopped by
using the device, whereas the control group experienced continual errhysis. The lung had almost re-
expanded at the end of the experiment in both groups. The effect of pulmonary re-expansion in the
control group was better than that in the experimental group at 120 min.
Conclusion: The novel expandable one-way valve device is a safe and useful tool for the treatment of
open chest trauma in emergency based on our animal experiment.
© 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction pneumothorax1 and accounts for 25% of all trauma mortality.2

Thoracic injuries are very common following blunt or pene-
trating trauma. They always lead to a blowing wound or open
* Corresponding author. Interventional Ward, Department of Medical Imaging,
900 Hospital of the Joint logistics Team, Dongfang Hospital, Xiamen University,
Fuzhou, Fujian, 350025, China.
** Corresponding author. Department of General Surgery, 900 Hospital of the Joint
logistics Team, Dongfang Hospital, Xiamen University, Fuzhou, Fujian, 350025,
China.
E-mail addresses: zhanghw1983@126.com (H. Zhang), flyfishwang@hotmail.
com (Y. Wang).
1
Weijin Yang and Youxu Zhou contributed equally to this work.
Traumatic pneumothorax is a leading cause of preventable mor-
tality in patients who experienced multiple traumas.3 During pe-
riods of war, open thoracic trauma is a more common injury and the
second most common cause of death.4 An accurate and rapid pre-
hospital response to life-threatening injuries is of great impor-
tance in both civil and military critical care. In civilian settings, most
thoracic trauma is managed using supplemental oxygen, tube
thoracostomy, and mechanical ventilation when necessary. How-
ever, none of these are likely to be available or advisable in
resource-poor settings.5
The utilization of damage control surgery is considered routine for
severe abdominal trauma, and only recently, this strategy has been

https://doi.org/10.1016/j.asjsur.2019.10.013
1015-9584/© 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: Yang W et al., An expandable one-way-valve device for chest wound treatment: Evaluation of open pneumothorax in a
canine model, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.013
2 W. Yang et al. / Asian Journal of Surgery xxx (xxxx) xxx
utilized in thoracic trauma. The general principles and goals of
thoracic damage control are similar to those employed in abdominal
trauma with expeditious management of unstable patients remaining
the primary focus. However, severe thoracic injuries are often rapidly
fatal without prompt intervention.21,22 Therefore, temporizing tech-
niques can be used as currency to buy time for physiological correc-
tion in exsanguinating patients before definitive treatment.
The updated Tactical Combat Casualty Care (TCCC) Guideline for
battle field management of open pneumothorax states that all open
and/or sucking chest wounds should be treated by immediately
applying a vented chest seal to cover the defect. If a non-vented
chest seal is used, the casualty may potentially develop a subse-
quent tension pneumothorax.6 At this point, commercially avail-
able vented chest seals incorporate a valve into their design to allow
a one-way flow of air out of the pleural space on exhalation but do
not permit air back into the pleural space on inspiration. For
example, the Asherman, Hyfin, and Bolin chest seals have been
recommended as faster and more reliable approaches to manage an
open pneumothorax than a three-sided dressing.7,8 However, while
those devices can discharge gas from the chest, they cannot stop
hemorrhage d another important cause of death.9 Therefore, there
is a clinical requirement for a device with a one-way valve that can
simultaneously discharge gas and stop hemorrhage.
Here we present findings from a novel chest wound treatment
device manufactured using expandable material with a one-way
valve, and compared this intervention with closed thoracic
drainage. We used a beagle dog model assessing response to open
pneumothorax. The aim of the study was to test the applicability of
the novel device as a preliminary step for the treatment of open
chest trauma, and to verify whether this device could both seal the
chest and discharge the gas while stopping blood loss.
2. Materials and methods
2.1. Animals
Ten male and ten female beagle dogs were included in this study.
The body weight of the dogs ranged from 12 to 18 kg. The dogs were
housed individually in cages (1.0
1.0
1.0 m). During the study, the
dogs were fed with a sufficient fixed quantity of processed dog food.
All dogs were fasted for 12 h before experimentation and then
randomly and equally divided into two groups. Use of all experi-
mental animals was approved by Zhenhe Laboratory Animal Co., Ltd.
(Fuzhou, Fujian Province, China). The study protocol was approved
by the Ethics Committee of Fuzhou General Hospital.
2.2. Materials
A novel chest wound treatment device was invented by our
group. The device had a composite structure and was composed of
polyvinyl alcohol. The main body was 8 cm long and 1.5 cm wide.
The inner core was a silicone hollow pipe, 9 cm long, with an
external diameter of 5 mm and an inner diameter of 3 mm. There
was a one-way valve at the end of this device (Fig. 1).
Single-use trocars (12 and 5 mm) were supplied by Kangji
Medical Instrument Co. Ltd. (Hangzhou, Zhejiang Province, China)
A Shimadzu X-ray system was supplied by Sonialvision Safire 17
(Shimadzu Corp., Kyoto, Japan). Fully automatic arterial blood gas
analysis was performed using a disposable i-STAT1 EG7þ chest
closing drainage device (Abbott, Abbott Park, IL, USA).
2.3. Methods
2.3.1. Establishment of arteriovenous passage
All dogs were anesthetized with ketamine and diazepam
Please cite this article as: Yang W et al., An expandable one-way-valve device for chest wound treatment: Evaluation of open pneumothorax in a
canine model, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.013
Fig. 1. A novel chest wound treatment device manufactured using expandable mate-
rial with a one-way valve.
(10 mg/kg; intramuscularly). Induction was conducted with an
intravenous bolus of ketamine and diazepam (12e15 mg/kg) and
delivery was maintained at a speed of 1 mg/kg/h. A femoral artery
catheter was placed inside the left femoral artery for blood sam-
pling (blood lactate and blood gas analysis). Another catheter was
placed in the left forelimb vein for anesthesia and intravenous fluid
infusion. In this study, a hemorrhagic shock model was established
in dogs to simulate the scenario of rescue in battlefields. Soldiers
who are wounded in battlefields are often associated with bleeding.
According to the damage control theory, in emergency conditions,
fetal wounds should be treated with emergency measures that are
simple, feasible, effective, and less damaging; after resuscitation,
then staged surgery can be planned to treat non-fetal wounds.
Hemorrhagic shock was induced with hemorrhage from the jugular
artery to maintain the mean arterial pressure at 40 mmHg in
20 min. Fluid resuscitation with Ringer's solution was initiated
30 min after the hemorrhagic shock.23 Warm lactated Ringer's
solution was administered intravenously during surgery at 5 mL/
kg/h. The chest, groin, and abdomen of each animal were shaved
and the skin prepared for aseptic surgery.
2.3.2. Establishment of an open pneumothorax model using a
minimally invasive procedure
The dogs were immobilized on the X-ray system after anesthesia
and arteriovenous catheterization. Following skin decontamination
with iodophor, we used a 5-mm trocar to stab the right-side of the
chest wall in the vicinity of the subcostal gutter of the upper rib, in
the fifth intercostal space approximately 10 cm from the sternum.
The trocar's inner core was withdrawn until the sharp blade
retraction click was noted. Forty minutes later, the pneumothorax
line (the compressed lung edge) was evaluated by X-ray (Fig. 2) and
the open pneumothorax model was validated.11 Blood sampling
was performed once more after the model was confirmed (blood
lactate and blood gas analysis).
2.3.3. Application of the novel device in the experimental group
A 12-mm single-use trocar was used to stab the right-side of the
chest wall in the vicinity of the subcostal gutter of the upper rib, in
the fifth intercostal space approximately 10 cm from the sternum.
The trocar was withdrawn until the sharp blade retraction click was
noted. Our test device was inserted immediately and the valve of
the 5-mm trocar was then turned off (Fig. 3). The device was con-
nected to a drainage pack. The speed and capacity of drained fluid
were recorded. Blood samples were obtained on one more occasion
after an hour (blood lactate and blood gas analysis). All subjects
underwent a chest radiograph once more.
 W. Yang et al. / Asian Journal of Surgery xxx (xxxx) xxx 3

2.4. Data analysis

Data are expressed as means ± standard error of the mean

(n ¼ 10). Between-group analysis (experimental group vs. control
group) was performed using two-way repeated measures analysis
of variance using SAS 9.4 (SAS Institute Inc., Cary, NC, USA). A
p < 0.05 was considered significantly different.

3. Results

3.1. Animal survival and the status of the device

After the 24-h experiment, all animals survived. In the experi-

mental group, eight lungs of the dogs almost re-expanded by the
end of the experiment. Nine test devices were completely swollen.
None of the devices fell off during the experimental period. In the
control group, nine lungs of the dogs had almost re-expanded by
120 min. One of the intrathoracic drainage tubes had been bitten off
during postoperative care. After puncture, chest-wall hemorrhage
was stopped by the test device, while errhysis was present in the
control group.

Fig. 2. The pneumothorax line (indicated by arrows) in an experimental dog before 3.2. Comparison of oxygen saturation and oxygen pressure between
intervention. two groups

Compared with the control group, the experimental group had

significantly lower levels of oxygen saturation (SO2, %) at 30 min
(91.8 ± 6.23 vs. 79.2 ± 4.66, p ¼ 0.0032; Table 1) and oxygen
pressure (PO2, mmHg) at 30 and 60 min post-intervention
(88.3 ± 5.91 vs. 52.3 ± 5.56, p < 0.0001 and 86 ± 4.71 vs.
72.2 ± 9.74, p ¼ 0.0351; Table 2). However, at 120 min post-
intervention, both indices were comparable in the control and
experimental groups.

3.3. Changes in oxygen saturation and oxygen pressure across

different time points

In the experimental group, the oxygen saturation level averaged

94.7% at the beginning of the experiment and decreased to 72.4%
after pneumothorax. It then slightly increased to 79.2% after
insertion of the device and reached 91.5% at the end of the exper-
iment (Fig. 4). Similar changes were observed in the oxygen

Fig. 3. Insertion of the novel device into the dog's chest. Table 1
Comparison of oxygen saturation (SO2, %) at each time point between experimental
and control groups of beagle dogs.
2.3.4. Application of closed thoracic drainage in the control group Time Control Experimental p
The dog's chest wall was stabbed as did in the experimental
Before pneumothorax 94.2 ± 1.23 94.7 ± 0.82 1
group. The trocar was withdrawn and a 30F intrathoracic drainage After pneumothorax 74.9 ± 4.18 72.4 ± 2.99 1
tube was inserted percutaneously into the right pleural space. The 30 min post-intervention 91.8 ± 6.23 79.2 ± 4.66 0.0032
drainage tube was linked with a water-sealed bottle. Blood samples 60 min post-intervention 91.9 ± 3.51 86.7 ± 11.5 1
were obtained once more after an hour (blood lactate and gas 120 min post-intervention 90.5 ± 4.45 91.5 ± 11.62 1

analysis). All animals underwent chest radiograph once more. Note: Data are the means ± standard deviation (n ¼ 10).

2.3.5. Postoperative care Table 2

Postoperative dogs were fed with a sufficient fixed quantity of Comparison of oxygen pressure (PO2, mmHg) at each time point between the
processed dog food after they had recovered from anesthesia. Be- experimental and control groups of beagle dogs.
tween 6 and 24 h post-surgery, we observed the survival of the Time Control Experimental p
dogs, the status of our device (position and swelling), and the
Before pneumothorax 81 ± 2.26 79.2 ± 2.49 1
occurrence of hemorrhage or errhysis in the chest wall. After 24 h, After pneumothorax 47.8 ± 3.91 44.5 ± 3.87 1
we pulled out the device in the experimental group while 30 min post-intervention 88.3 ± 5.91 52.3 ± 5.56 <0.0001
extracting the closed chest drainage tube and the intrathoracic 60 min post-intervention 86 ± 4.71 72.2 ± 9.74 0.0351
drainage tube in the control group. We then sutured the wound in 120 min post-intervention 82.8 ± 7.45 84.7 ± 16.99 1

the dog's chest. Note: Data are the means ± standard deviation (n ¼ 10).

Please cite this article as: Yang W et al., An expandable one-way-valve device for chest wound treatment: Evaluation of open pneumothorax in a
canine model, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.013
4 W. Yang et al. / Asian Journal of Surgery xxx (xxxx) xxx

Fig. 4. Changes in oxygen saturation (SO2, %) level at different time points in the experimental and control groups.

pressure level in the experimental dogs, which markedly decreased 4. Discussion

from 79.2 mmHg at the beginning to 44.5 mmHg after pneumo-
thorax. It then increased to 52.3 mmHg after insertion of the device
and finally reached 84.7 mmHg by the end of the experiment
(Fig. 5).
In the control group, the oxygen saturation level averaged 94.2%
at the beginning and decreased to 74.9% after pneumothorax. It
then increased to 91.8% after insertion of the device and slightly
decreased to 90.5% by the end of the experiment (Fig. 4). Similarly,
the oxygen pressure level initially decreased from 81.0 mmHg at
the beginning to 47.8 mmHg after pneumothorax. It then increased
to 88.30 mmHg after insertion of the device and subsequently
dropped to 82.8 mmHg by the end of the experiment (Fig. 5).
3.4. Chest radiography of the open pneumothorax model
The chest radiograph of the open pneumothorax model showed
that, by the end of the experiment, the pneumothorax line had
almost faded in the experimental (Fig. 6) and control (Fig. 7) groups.
However, the lung had almost re-expanded.
This study has invented a novel device for the treatment of open
chest wound in emergency. In the animal experiment, we observed
no active hemorrhage or errhysis in the chest wall of experimental
dogs treated by this device, thus demonstrating its applicability.
The main body of this novel device is composed of a high polymer
material d polyvinyl alcohol d in a compressed state, with a one-
way valve at its end. When the device is inserted into the wound, it
absorbs blood and swells immediately. In this way, it can block off
the chest wound while discharging gas or liquid from the chest
through the one-way valve. This device is handy, small, and
exquisite. In addition, it can be easily operated by one person.
Importantly, the device meets physical requirements for both
military and civilian uses.
The “golden hour” is typically defined as the hour-long window
of clinical opportunity after trauma. The survival rate may be
improved with timely treatment of pneumothorax. Otherwise, it
may result in life-threatening symptoms such as severe respiratory
distress, hyper-resonance, absence of breathing sounds, tracheal
deviation, and unstable hemodynamics.12,13 Following the direction

Fig. 5. Changes in oxygen pressure (PO2, mmHg) level at different time points in the experimental and control groups.

Please cite this article as: Yang W et al., An expandable one-way-valve device for chest wound treatment: Evaluation of open pneumothorax in a
canine model, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.013
 W. Yang et al. / Asian Journal of Surgery xxx (xxxx) xxx 5

Fig. 6. Changes in chest radiograph of the dog model of open pneumothorax before (A) and after (B) experimentation (experimental group).

of thoracic damage control, temporary chest closure allows us to
rapidly close the thoracic cavity and get these critically ill patients
to the ICU, where resuscitation is more efficient. Some researchers
recommend using a damage-control strategy and temporary chest
closure in patients with thoracic injuries and clinical disseminated
intravascular coagulation, hypothermia, and academia.24
The study reported here has examined the ability of the
expandable one-way-valve device to treat open pneumothorax in
dogs as a first-line therapy. In the experimental dogs, those indices
that were initially affected by the device inserted into the chest
wound had almost gradually returned to normal levels by the end
of the experiment. The pneumothorax line had also faded away by
the end of the experiment, which implied that the lung had almost
re-expanded. The blood gas pH changed a little before and after the
experiment. Although the oxygen saturation and oxygen pressure
in the experimental group did not recover as fast as those in the
control group, the indices for both groups were close to normal
120 min after insertion of the device. These results indicate that it is
safe and feasible to use our device for the treatment of open
pneumothorax in animals. Despite its slightly smaller effect than
the golden standard (closed thoracic drainage), our device can be
used for first-line treatment through operation by one person.
In the control group, the intrathoracic drainage tube was
inserted percutaneously into the right pleural space. Faster changes
occurred in the main indices compared with those in the experi-
mental group, and this difference may be due to the pipe diameter
of the intrathoracic drainage tube being bigger than our device.
Although oxygen saturation and oxygen pressure significantly
improved after a short time, these indices eventually declined over
time. Catheter malpositioning may be the primary cause, as this

Fig. 7. Changes in chest radiograph of the dog model of open pneumothorax before (A) and after (B) experimentation (control group).

Please cite this article as: Yang W et al., An expandable one-way-valve device for chest wound treatment: Evaluation of open pneumothorax in a
canine model, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.013
6 W. Yang et al. / Asian Journal of Surgery xxx (xxxx) xxx
phenomenon was observed in several dogs.
Traditional approaches to the diagnosis and management of
pneumothorax are being challenged, and physicians should main-
tain an open mind regarding new approaches to this condition.17e19
The device reported in this study is soft when it absorbs blood and
swells. Consequently, there is a slim chance that the lung lobe can
be harmed. Based on our study, we should be prepared to translate
these lessons learned to care for injuries in the battlefield or in
areas lacking resource. For significant thoracic trauma, provision of
equipment and necessary training in applying vented chest seals
with one-way valves may be life-saving. It is also possible that
simple “rodlike” devices coupled with a vented chest seal may also
be life-saving.
There were a few limitations in this study. First, the novel device
could occasionally fall off during the treatment. In addition, the size
of this device was limited. However, this animal study has focused
on a potentially survivable wound, examples being gunshot or knife
wounds. If the hole of the wound is bigger than our device e.g., by a
rifle shot, we believe such victims would die immediately. Second,
the sample size of the study was relatively small, but given the big
size of our experimental animals, the sample size is deemed
reasonable. Third, the amount of blood loss from the thoracic injury
was not quantified because we were unable to visualize the inside
of the chest or the amount of internal hemorrhage, and only local
hemostasis could be seen. To remedy this shortcoming, we will
inject increasing volumes of blood as well as air in the subjects in
our next study. Last but not least, the control group was not treated
with vented chest seal (Halo, Bolin, and Asherman) as a comparator.
Since the goal of our animal experiment was to evaluate the
effectiveness and safety of our new device for the management of
open chest wound in emergency; therefore, closed thoracic
drainage was applied in our control group. We did fully understand
that closed thoracic drainage is not easily available in the battlefield
or scene of the accident. Needless to say, the head to head com-
parison between our new device and one of vented chest seals
(Halo, Bolin, and Asherman) is needed in the future.
Despite the limitations, the present study allows us to improve
the device materials for the treatment of open pneumothorax in
emergency conditions. Further study is needed to collect data
relating to the cost efficiency of this novel device.
5. Conclusion
An expandable one-way-valve device is tested and deemed safe
and useful for the treatment of open chest trauma. Compared with
the traditional closed thoracic drainage, our device can be used in
the first line conveniently and effectively. This study has verified
the applicability and safety of the device through animal experi-
ments, laying the foundation for clinical trials.
Ethics approval and consent to participate
The study protocol was approved by the Ethics Committee of
900 Hospital of the Joint logistics Team and Xiamen University
(Fuzhou, Fujian Province, China).
Consent for publication
Not applicable.
Please cite this article as: Yang W et al., An expandable one-way-valve device for chest wound treatment: Evaluation of open pneumothorax in a
canine model, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.013
Availability of data and materials
The datasets analysed in the current study are available from the
corresponding author on reasonable request.
Funding
This study was supported by the Key Project of 900 Hospital of
the Joint logistics Team (2015J01), the Key Medicine Project of PLA
(CNJ15J004), the National Science and Technology Major Project of
China (2018ZX09J18), the Natural Science foundation of Fujian
Province (NO.2017J01317, NO.2017J01327), B. Braun Anesthesio-
logical Research Foundation (SH50)and the Cooperate Project of
Fujian Province (2017I0015).
Declaration of competing interest
The authors declare that they have no competing interests.
Acknowledgements
The authors thank the staff from the Animal Experimental
Center and the Department of Pathology at 900 Hospital of the Joint
logistics Team for their help.
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