Flail chest

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1. FLAIL CHEST Dr Pooja Pandey JR-1 MS General Surgery Mayo institute of Medical Sciences,Barabanki

2. Content Introduction Causes Types of Flail Chest Pathophysiology of Flail chest Clinical Features Diagnostic modalities Management of Flail Chest Complications Prognosis

3. INTRODUCTION A flail chest occurs when a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall. This is usually defined as at least two fractures per rib (producing a free segment), in at least three ribs.

4. Flail chest is an injury that involves 3 or more consecutive rib fractures in two or more locations, producing a comminuted fracture with a free-floating, unstable bony segment that is detached from the remainder of the chest wall. Associated injuries are common and should be aggressively sought. Pulmonary contusion is the most common local disturbance in association with flail segment. Mortality is significant.

5. Most Common – Vehicle Accidents (76%) Second most common – Falls, especially in elderly population (weak, frail bones) (14%) Third most common – blunt trauma in children, especially those with genetic conditions, eg. Osteogenesis Imperfecta. CAUSES

6. Blunt Trauma- Blunt force to chest. E.g. automobile crashes and falls. Penetrating Trauma- Projectile that enters chest causing small or large hole. E.g. gun shot and stabbing. Compression Injury- Chest is caught between two objects and chest is compressed.

7. TYPES OF FLAIL CHEST ANTERIOR – Near costochondral region POSTERIOR – safer LATERAL - in ribs shafts FLAIL STERNUM

8. CLINICAL FEATURES Shortness of Breath Paradoxical Movement Bruising/Swelling Crepitus (Grinding of bone ends on palpation) Tachycardia Hypotension

9. During normal inspiration, the diaphragm contracts and intercostal muscles pull the rib cage out. Pressure in the thorax decreases below atmospheric pressure, and air rushes in through the trachea.  During normal expiration, the diaphragm and intercostal muscles relax increasing internal pressure, allowing the abdominal organs to push air upwards and out of the thorax. The flail segment will be pulled in with the decrease in pressure while the rest of the rib cage expands.   a flail segment will also be pushed out while the rest of the rib cage contracts.

10. ASSESMENT Frequent and prompt Respiratory assessment Adequate oxygenation Analgesia to improve ventilation. Clearing secretion Stabilize the thoracic cage Deep breathing exercises Intubation and mechanical ventilation may be required to prevent further hypoxia

11. Diagnosis Clinical examination for bruises, paradoxical movement of flail segment. Chest X – Ray Computed Tomography

12. Principle of Management of Flail Chest ABC’s with c-spine control as indicated High Flow oxygen Adequate analgesia (Including opiates) Intra-plural local analgesia Observe the patient for development of Pneumothorax and even worse Tension Pneumothorax If Tension Develops Needle Decompress affected side • Surgery -> internal operative fixation. Rapid Transport! Remember a True Emergency

13. Splint and Bandage Use Trauma bandage and Triangular Bandages to splint ribs. Can also place a bag of D5Won area and tape down. (The only good use of D5WI can find)

14. Analgesia -Mainstay Opioid Analgesics (risk of respiratory depression) NSAIDs Thoracic or high lumbar Epidurals with or without Opioid additives. Posterior rib blocks (lasts up to 24 hours) Instillation of L.A. into pleural space through ICD (controversial)

15. Intubation & Ventilation (Rarely indicated) Indicated for hypoxia due to pulm onary contusions. The severity of flail injuries and associated contusions frequently require endotracheal intubation and positive pressure mechanical ventilation- IPPV. Double lumen tracheal tube with each tube connected to a different ventilator Optimal ventilatory management is crucial Judicial IV fluids to avoid fluid overload. 

16. Management Chest Tube Insertion To treat hemothorax To treat pneumothorax

17. Management Rib Fracture Fixation Usually not required Preferred choice before intubation & ventilation.

18. Physiotherapy To aid better drainage of secretions To rebuild musculature To reposition chest wall Coughing exercises Resistance exercises Trunk exercises

19. Rehabilitation 12 week outpatient program for at least 3 days a week patient should be seen for 30–45 minutes a day after a 5-10 minute warm up session. After discharge, patient should be given an exercise regimen to be performed at home.

20. COMPLICATIONS Pneumonia ARDS Lung abscess Emphysema Hypoventilation Atelectasis Mediastinal flutter (mediastinal structures tend to swing back n forth)

21. Prognosis Mortality Rate of flail chest ranges from 10- 25% Ventilation has little effect on outcome

22. References Millers Anesthesia Morgan’s Clinical Anesthesia Athanassiadi, Kalliopi, Michalis Gerzounis, Nikolaos Theakos. Management of 150 flail chest injuries: analysis of risk factors affecting outcome. European Journal of Cardio- thoracic surgery 26. (2004). Wikipedia www.trauma.org Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury Sandra Wanek, MD, John C. Mayberry, MD, FACS Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma 1994;37(6):975 – 9.