Flail Chest


Background

Etiologies

Pathophysiology

Symptoms

Physical exam

Diagnostic tests

Treatment

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

Disposition

  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