Flail Chest





Physical exam

Diagnostic tests


  1. ATLS primary surveyy
  2. Temporizing measures
  3. General treatment goals
  4. Other treatment


  1. Admit to ICU

Diagram of flail chest.

Immediately Life-Threatening Chest Injuries
  Physical Exam Investigations Management
Airway Obstruction - Anxiety, stridor, hoarseness, altered mental status
- Apnea, cyanosis
- Do not wait for ABG's to intubate - definitive airway management
- intubate early
Tension Pneumothorax
- a clinical diagnosis
- one-way valve causing accumulation of air in pleural space
- Respiratory distress, tachycardia, distended neck veins, cyanosis, asymmetry of chest wall motion
- Tracheal deviation away from pneumothorax
- Percussion hyperresonnance
- Unilateral absence of breath sounds, hypotension
- Non-radiographic diagnosis - large bore IV needle, 2nd ICS mid clavicular line, followed by chest tube in 5th ICS, anterior axillary line
- ICS = intercostal space
Open Pneumothorax
- air entering chest from wound rather than trachea
- Gunshot or other wound (hole > 2/3 tracheal diameter) +/- exit wound
- Unequal breathsounds
- ABG's: decreased pO2 - Air-tight dressing sealed on 3 sides
- Chest tube
- Surgery
Massive Hemothorax
- > 1500 cc blood loss in chest cavity
- Pallor, flat neck veins, shock
- Unilateral dullness
- Absent breath sounds, hypotension
- Upright CXR: costophrenic blunting - Restore blood volume
- Chest tube
- May receive thoracotomy: > 1500 cc total blood volume
200 cc/hr continued drainage
Flail Chest
- Free-floating segment of chest wall due to > 4 rib fractures, each at 2 sites
- Underlying lung contusion (cause of morbidity and mortality)
- paradoxical movement of flail segment
- palpable crepitus of ribs
- decreased air entry on affected side
- ABGs: decreased pO 2 , increased pCO 2
- CXR: rib fractures, lung contusion
- O2 + fluid therapy + pain control
- Judicious fluid therapy in absence of systemic hypotension
- Positive pressure ventilation
- +/- intubation and ventilation
Cardiac Tamponade - penetrating wound (usually)
- Beck's triad (hypotension, distended neck veins, muffled heart sounds)
- pulsus paradoxus
- Kussmaul's sign
- ECHO - IV fluids
- pericardiocentesis
- open thoracotomy

  Physical Exam Investigations Management
Pulmonary Contusion - Blunt trauma to chest
- Interstitial edema impairs compliance and gas exchange
- CXR: areas of opacification of lung within 6 hours of trauma - maintain adequate ventilation
- monitor with ABG, pulse oximeter and ECG
- chest physiotherapy
- positive pressure ventilation if severe
Ruptured Diaphragm - Blunt trauma to chest or abdomen (e.g. high lap belt in MVC) - CXR:  abnormality of diaphragm/lower lung fields/NG tube placement   
- CT scan and endoscopy - sometimes helpful for diagnosis
- laparotomy for diaphragm repair and because of associated intra-abdominal injuries
Esophageal Injury - Usually penetrating trauma (pain out of proportion to degree of injury) - CXR: mediastinal air (not always)
- Esophagram (Gastrograffin)      
- Flexible esophagoscopy
- Early repair (within 24 hrs.) improves outcome but all require repair
Aortic Tear    
- 90% tear at subclavian (near ligamentum arteriosum), most die at scene
- salvageable if diagnosis made rapidly
- Sudden high speed deceleration (e.g. MVC, fall, airplane crash), complaints of chest pain, dyspnea, hoarseness (frequently absent)

- Decreased femoral pulses, differential arm BP (arch tear)
- CXR, CT scan, transesophageal echo (TEE), aortography (gold standard)
- see below for CXR features
- Thoracotomy (may treat other severe injuries first)
Blunt Myocardial Injury (Rare) - Blunt trauma to chest (usually in setting of multi-system trauma and therefore difficult to diagnose)      
- Physical examination: overlying injury, i.e. fractures, chest wall contusion
- ECG: arrhythmias, ST changes
- Patients with a normal ECG and normal hemodynamics never get dysrhythmias
- O2
- Antiarrhythmic agents
- Analgesia