Flail Chest - Clinicals, Diagnosis, and Management

Trauma

Clinicals - History

Fact Explanation
History of blunt trauma to chest A flail chest occurs when a segment of the chest wall loses its bony continuity with the thoracic cage. A flail segment, occurs when three or more consecutive ribs are fractured in at least two places.This flail segment paradoxically moves inward during inspiration and outward during expiration.. There is also an associated pulmonary contusion , resulting from blunt trauma. Commonest causes for this presentation are road traffic accidents, falls and assaults. In the elderly even low energy impact such as accidental falls can cause flail segments due to the fragility of bones. Yet, in contrast only 1% of serious impacts in children result in a flail segment due to pliability of the thoracic cage. History of blunt trauma to chest
A flail chest occurs when a segment of the chest wall loses its bony continuity with the thoracic cage. A flail segment, occurs when three or more consecutive ribs are fractured in at least two places.This flail segment paradoxically moves inward during inspiration and outward during expiration.. There is also an associated pulmonary contusion , resulting from blunt trauma. Commonest causes for this presentation are road traffic accidents, falls and assaults. In the elderly even low energy impact such as accidental falls can cause flail segments due to the fragility of bones. Yet, in contrast only 1% of serious impacts in children result in a flail segment due to pliability of the thoracic cage.
Difficulty in breathing The typical paradoxical movement of the flail segment causes decreased lung compliancy and increased lung resistance which when associated with a lung contusion results in an increased breathing effort. In addition there is shunting of air back and forth between the two lungs, which adds to the difficulty in breathing. Difficulty in breathing
The typical paradoxical movement of the flail segment causes decreased lung compliancy and increased lung resistance which when associated with a lung contusion results in an increased breathing effort. In addition there is shunting of air back and forth between the two lungs, which adds to the difficulty in breathing.
Chest pain Rib fractures and the underlying lung contusion results in localized chest wall pain which increases with deep inspiration, coughing and movement. Chest pain
Rib fractures and the underlying lung contusion results in localized chest wall pain which increases with deep inspiration, coughing and movement.
Hemoptysis This is usually due to the underlying lung contusion. Hemoptysis
This is usually due to the underlying lung contusion.

Clinicals - Examination

Fact Explanation
Paradoxical respitaiton Once a segment of the rib cage becomes
sufficiently disconnected from the rest of the thorax, there is independent movement. Consequently, during inspiration the contraction of the diaphragm and other respiratory
muscles move the flail segment inwards and conversely during expiration the flail segment moves outwards, giving rise to the term
‘paradoxical respiration’. Practically, the ‘floating segment' is seen less frequently than expected. Patient may even develop this sign later during the hospital stay. The real significance of the detection of paradoxical movement lies in the fact that the severity of trauma necessary to produce a flail segment has implications
with respect to damage of underlying intra thoracic structures. Paradoxical motion also disrupts the mechanics of ventilation which leads to a decrease in total lung capacity (TLC) and functional residual capacity (FRC)
Paradoxical respitaiton
Once a segment of the rib cage becomes
sufficiently disconnected from the rest of the thorax, there is independent movement. Consequently, during inspiration the contraction of the diaphragm and other respiratory
muscles move the flail segment inwards and conversely during expiration the flail segment moves outwards, giving rise to the term
‘paradoxical respiration’. Practically, the ‘floating segment' is seen less frequently than expected. Patient may even develop this sign later during the hospital stay. The real significance of the detection of paradoxical movement lies in the fact that the severity of trauma necessary to produce a flail segment has implications
with respect to damage of underlying intra thoracic structures. Paradoxical motion also disrupts the mechanics of ventilation which leads to a decrease in total lung capacity (TLC) and functional residual capacity (FRC)
Impaired chest wall movements Mechanically impaired chest wall movement due to rib fractures, underlying lung contusion and associated pain on movement. Impaired chest wall movements
Mechanically impaired chest wall movement due to rib fractures, underlying lung contusion and associated pain on movement.
Splinting respirations Voluntary splinting as a result of pain. Splinting respirations
Voluntary splinting as a result of pain.
Tachycardia This is due to hypoxia which is a serious consequence of flail chest. This can be caused by a number of factors including ventilation/ perfusion mismatch secondary to contusion,
hematoma or alveolar collapse, and inadequate tissue oxygen delivery.
Tachycardia
This is due to hypoxia which is a serious consequence of flail chest. This can be caused by a number of factors including ventilation/ perfusion mismatch secondary to contusion,
hematoma or alveolar collapse, and inadequate tissue oxygen delivery.
Cyanosis This is due to hypoxia which is a serious consequence of flail chest and can be caused by a number of factors including ventilation/ perfusion mismatch secondary to contusion, hematoma or alveolar collapse, and inadequate tissue oxygen delivery. Cyanosis
This is due to hypoxia which is a serious consequence of flail chest and can be caused by a number of factors including ventilation/ perfusion mismatch secondary to contusion, hematoma or alveolar collapse, and inadequate tissue oxygen delivery.
Flushed skin, full pulse, tachypnea, dyspnea, extrasystoles, muscle twitches, hand flaps These signs are due to hypercarbia
which is consequence of inadequate ventilation and decreased levels of consciousness leading to carbon dioxide retention.
Flushed skin, full pulse, tachypnea, dyspnea, extrasystoles, muscle twitches, hand flaps
These signs are due to hypercarbia
which is consequence of inadequate ventilation and decreased levels of consciousness leading to carbon dioxide retention.
Hypotension This can manifest as a consequence of hypoxia due to respiratory insufficiency or as a sign of shock due to cardiovascular compromise associated with major injuries. Hypotension
This can manifest as a consequence of hypoxia due to respiratory insufficiency or as a sign of shock due to cardiovascular compromise associated with major injuries.
Bony crepitations This is due to fractured ribs that form an independently moving segment of the thoracic wall. Bony crepitations
This is due to fractured ribs that form an independently moving segment of the thoracic wall.
Bony step offs,ecchymosis, edema and associated erythema and tenderness over the chest wall. These signs over the flail chest segment are common at presentation, this is due to chest wall contusion and multiple rib fractures Bony step offs,ecchymosis, edema and associated erythema and tenderness over the chest wall.
These signs over the flail chest segment are common at presentation, this is due to chest wall contusion and multiple rib fractures

Investigations - Diagnosis

Fact Explanation
Plain chest radiograph The diagnosis is made clinically and is only aided by radiography. This is the single most important investigation for patients sustaining thoracic trauma. An erect film is best and allows for optimal assessment of lung expansion and assessment of free air or blood
within the thoracic cavity. The plain
chest radiograph is an excellent diagnostic tool, allowing for the diagnosis of rib fractures (either single or multiple), pulmonary contusion, hemothorax, pneumothorax,
sternal fracture, widened mediastinum and
many other associated injuries. Flail chest diagnosis by chest X-ray sometimes encounters difficulties, especially when a fracture
line is located in the anteromedial part of the chest wall at the costochondral junction. In such cases, a chest CT scan may help the diagnosis
Plain chest radiograph
The diagnosis is made clinically and is only aided by radiography. This is the single most important investigation for patients sustaining thoracic trauma. An erect film is best and allows for optimal assessment of lung expansion and assessment of free air or blood
within the thoracic cavity. The plain
chest radiograph is an excellent diagnostic tool, allowing for the diagnosis of rib fractures (either single or multiple), pulmonary contusion, hemothorax, pneumothorax,
sternal fracture, widened mediastinum and
many other associated injuries. Flail chest diagnosis by chest X-ray sometimes encounters difficulties, especially when a fracture
line is located in the anteromedial part of the chest wall at the costochondral junction. In such cases, a chest CT scan may help the diagnosis
Computed tomography (CT) Provides much more sensitive information than a plain radiograph. For excluding rib fractures, a CT is more sensitive than a chest radiograph. Using a CT scan also could help in the diagnosis of lung contusion and in excluding the
rupture of the great vessels .The use of CT is mainly limited by the fact that the patient has to be transferred to the scanner. This is often not possible in a hemodynamically unstable trauma patient.
Computed tomography (CT)
Provides much more sensitive information than a plain radiograph. For excluding rib fractures, a CT is more sensitive than a chest radiograph. Using a CT scan also could help in the diagnosis of lung contusion and in excluding the
rupture of the great vessels .The use of CT is mainly limited by the fact that the patient has to be transferred to the scanner. This is often not possible in a hemodynamically unstable trauma patient.
Magnetic resonance imaging (MRI) Can aid in diagnosis of flail chest and underlying injuries like lung, hemothorax, alveolar collapse, damage to greater vessels, but usage is limited by cost and availability. In addition the fact that there are long periods of patient isolation, as well as the availability of local radiological expertise. Magnetic resonance imaging (MRI)
Can aid in diagnosis of flail chest and underlying injuries like lung, hemothorax, alveolar collapse, damage to greater vessels, but usage is limited by cost and availability. In addition the fact that there are long periods of patient isolation, as well as the availability of local radiological expertise.

Investigations - Management

Fact Explanation
Full blood count As a routine test in a patient who has sustained major trauma to assess the hemoglobin status and the platelet count. Full blood count
As a routine test in a patient who has sustained major trauma to assess the hemoglobin status and the platelet count.
Electrolytes As a routine investigation to assess complications associated with major injuries like hyperkalemia. Electrolytes
As a routine investigation to assess complications associated with major injuries like hyperkalemia.
Cross matching Will be required in chest trauma patient as blood transfusion may be required. Cross matching
Will be required in chest trauma patient as blood transfusion may be required.
Arterial blood gases Arterial blood gases should be assessed in order to detect hypoxaemia, hypercarbia and any abnormality in the acid–base balance. Arterial blood gases
Arterial blood gases should be assessed in order to detect hypoxaemia, hypercarbia and any abnormality in the acid–base balance.
Electrocardiograph monitoring Electrocardiograph monitoring should be carried out for cardiac arrhythmias or ischaemia. Electrocardiograph monitoring
Electrocardiograph monitoring should be carried out for cardiac arrhythmias or ischaemia.

Management - Supportive

Fact Explanation
Analgesia It is of paramount importance to administer appropriate and adequate analgesia. Opioid analgesics like morphine(IM 7.5 mg) can be used(caution should be observed as it may cause centrally mediated respiratory
depression). Alternatively intercostal nerve block can be performed by infiltrating 0.25–0.5% Bupivicaine. Epidural analgesia is also an
excellent way of achieving pain relief.Administration of analgesia allows for
improved chest wall excursion and alveolar ventilation, helping to correct the frequently encountered hypoxia.
Analgesia
It is of paramount importance to administer appropriate and adequate analgesia. Opioid analgesics like morphine(IM 7.5 mg) can be used(caution should be observed as it may cause centrally mediated respiratory
depression). Alternatively intercostal nerve block can be performed by infiltrating 0.25–0.5% Bupivicaine. Epidural analgesia is also an
excellent way of achieving pain relief.Administration of analgesia allows for
improved chest wall excursion and alveolar ventilation, helping to correct the frequently encountered hypoxia.
High flow oxygen Supplemental high flow oxygen should
be administered in all patients with flail chest. It increases alveolar ventilation and corrects hypoxia.
High flow oxygen
Supplemental high flow oxygen should
be administered in all patients with flail chest. It increases alveolar ventilation and corrects hypoxia.
Fluid Resuscitation Is required in patients with trauma to prevent shock.Trauma patients with flail chest and/or pulmonary contusion should not be excessively
fluid restricted but rather be resuscitated as necessary with isotonic crystalloid or colloid solution to maintain adequate tissue perfusion. Once adequately resuscitated, unnecessary
fluid administration should be avoided.
Fluid Resuscitation
Is required in patients with trauma to prevent shock.Trauma patients with flail chest and/or pulmonary contusion should not be excessively
fluid restricted but rather be resuscitated as necessary with isotonic crystalloid or colloid solution to maintain adequate tissue perfusion. Once adequately resuscitated, unnecessary
fluid administration should be avoided.
Intercoastal tube insertion Chest tube insertion is considered only in those with pneumothorax or haemothorax. If a chest tube is in situ, intrapleural local analgesia( 20 to 30 mL of 0.5% bupivacaine) can be used. Intercoastal tube insertion
Chest tube insertion is considered only in those with pneumothorax or haemothorax. If a chest tube is in situ, intrapleural local analgesia( 20 to 30 mL of 0.5% bupivacaine) can be used.
Nasotrachical aspiration Nasotracheal aspiration and fibreoptic bronchoscopy along with aggressive physiotherapy and humidification of
inspired air is performed to clear secretions and to avoid atelectasis that leads to infection.
Nasotrachical aspiration
Nasotracheal aspiration and fibreoptic bronchoscopy along with aggressive physiotherapy and humidification of
inspired air is performed to clear secretions and to avoid atelectasis that leads to infection.
Fixed Bandage The function of a fixed bandage
(adhesive plaster strapping) is to reduce pain and possibly to render assistance in coughing. This method of fixation however, has a disadvantage, as it reduces
ventilation of the half of the thorax in question and in so doing promotes the formation of atelectasis and respiratory
insufficiency.
Fixed Bandage
The function of a fixed bandage
(adhesive plaster strapping) is to reduce pain and possibly to render assistance in coughing. This method of fixation however, has a disadvantage, as it reduces
ventilation of the half of the thorax in question and in so doing promotes the formation of atelectasis and respiratory
insufficiency.
Tracheotomy Early tracheostomy (after the third day of hospitalization) is usually performed in order to facilitate the drainage of bronchial secretions.The frequency of bronchial
toilet depended on the cooperation of a patient to cough, is assisted by the physiotherapists and is used 2—4 times per day.
Tracheotomy
Early tracheostomy (after the third day of hospitalization) is usually performed in order to facilitate the drainage of bronchial secretions.The frequency of bronchial
toilet depended on the cooperation of a patient to cough, is assisted by the physiotherapists and is used 2—4 times per day.
Physiotherapy The use of optimal analgesia and aggressive chest physiotherapy should be employed to minimize the likelihood of respiratory failure. Physiotherapy
The use of optimal analgesia and aggressive chest physiotherapy should be employed to minimize the likelihood of respiratory failure.

Management - Specific

Fact Explanation
Mechanical Ventilation This is the traditional treatment of ‘internally splinting’ the chest until fibrous union of the broken ribs occurs.

However this method is reserved for patients developing respiratory failure despite adequate analgesia and oxygen.

Modes of ventilatory support include positive end-expiratory pressure (PEEP), and continuous positive airway pressure (CPAP).

Indications for ventilation in patients with flail chest are shock, several associated injuries, severe head injuries and respiratory insufficiency usually attributed to an underlying pulmonary disease, such as chronic obstructive pulmonary disease.

Obligatory mechanical ventilation is not necessary as this technique requires prolonged time on the ventilator, resulting in secondary chest infections and some times death.
Mechanical Ventilation
This is the traditional treatment of ‘internally splinting’ the chest until fibrous union of the broken ribs occurs.

However this method is reserved for patients developing respiratory failure despite adequate analgesia and oxygen.

Modes of ventilatory support include positive end-expiratory pressure (PEEP), and continuous positive airway pressure (CPAP).

Indications for ventilation in patients with flail chest are shock, several associated injuries, severe head injuries and respiratory insufficiency usually attributed to an underlying pulmonary disease, such as chronic obstructive pulmonary disease.

Obligatory mechanical ventilation is not necessary as this technique requires prolonged time on the ventilator, resulting in secondary chest infections and some times death.
Surgical Fixation Particularly useful in a selected group with
isolated or severe chest injury and pulmonary contusion. Method of surgical fixation include: plate fixation (U-plate,anatomical rib plate, etc) and intra medullary stabilization with Kirschner wires, Rehbein plate, rib splint. Recent NICE guidelines recommend surgical stabilization of
a flail chest as it can shorten the duration of ventilator support and reduce the morbidity and mortality associated with prolonged mechanical
ventilation. Positives of surgical fixation are decreased pain, improved mechanics compared with preoperative performance, rapid separation from mechanical ventilation and excellent
return-to-work outcomes. Disadvantages of operative stabilization is that it
requires general anesthesia which is inherently risky for trauma patients. The surgical technique involved in stabilization can be
difficult, time consuming, and the additional dissection is required in addition implanted foreign bodies can contribute to
chronic osseous and soft tissue infections
Surgical Fixation
Particularly useful in a selected group with
isolated or severe chest injury and pulmonary contusion. Method of surgical fixation include: plate fixation (U-plate,anatomical rib plate, etc) and intra medullary stabilization with Kirschner wires, Rehbein plate, rib splint. Recent NICE guidelines recommend surgical stabilization of
a flail chest as it can shorten the duration of ventilator support and reduce the morbidity and mortality associated with prolonged mechanical
ventilation. Positives of surgical fixation are decreased pain, improved mechanics compared with preoperative performance, rapid separation from mechanical ventilation and excellent
return-to-work outcomes. Disadvantages of operative stabilization is that it
requires general anesthesia which is inherently risky for trauma patients. The surgical technique involved in stabilization can be
difficult, time consuming, and the additional dissection is required in addition implanted foreign bodies can contribute to
chronic osseous and soft tissue infections

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