Flail chest. Wanna see?

[Mateo_1387]

Ok, I guess I will take a stab at the questions

What is flail chest?

If I am remembering my textbook answer correctly (no I am not looking!) when two or more (or is it 3 or more) ribs are broken in two or more places

What caused it?

As others have said, major trauma to the chest

What are your primary short term concerns?

A broken rib puncturing the lung, causing a pneumothorax (I am not really clear as to the differences between a regular pnumo and a tension pnumo, but I know both are bad). Or hemothorax, or hemopneumothorax... either way, not good. How possible is it for the fractured ribs to actually damage the heart? I would assume if it is in the right place, on a relatively skinny person it could, which would be bad bad bad.

So pretty much my main short term concerns are breathing problems

Longer term concerns?

Um, complications from above?

Load and go/stay and play? Why?

Treatment?

I am pretty sure regardless of BLS or ALS, I would load and go. BLS there isn't a whole hell of a lot I can do for them except use the BVM if their breathing gets really bad (if I am remembering correctly, the BVM uses positive pressure ventilations, which would negate the flail chest because it would not be negative pressure on inhalation, so the entire chest would expand w/ every breath). We don't have x-ray/ MRI vision in the field, so although we can guess, we can't know for sure what all damage is done beneath the skin on this guy. Whatever caused the force strong enough to break multiple ribs is going to put me on high alert for other injuries (not that I am triaging based on MOI, just higher index of suspicion). If he does have a punctured lung, he needs a chest tube, and while ALS providers could do a chest decompression in the field, I am pretty sure that is only a temporary fix. Either way, this guy probably needs surgical interventions (is a chest tube officially a surgery, since it is often done in the ER?)

First question you should answer, just so you will learn, and have more knowledge than before is 'what is the difference between a pneumothorax and a tension pneumothorax?

I like that you think about other possible injuries present with an injury such as a flail chest. Besides damage to the heart, what other injuries could you suspect?

The one time I had seen this in the field, we put a liter bag of LR over the flail segment to act as a counter weight and stabilize the chest wall... And if I'm thinking through this correctly, even with a BVM there would be negative pressure in the chest cavity. A BVM does act on positive pressure, but the action of exhalation would create negative pressure. A chest tube is a surgical procedure as well... Remember fixing an ingrown nail could technically be considered a surgical procedure.

Correct me please if I'm wrong guys... wouldn't be the first time and certainly wouldn't be the last

Think of the lung like a balloon that can expand and "suck" air in or relax and "Blow" air out. As long as it is in relax mode, it has positive pressure in it. When it expands, it creates a negative pressure and sucks air in. That's where the BVM comes in. Rather than letting the balloon (lung) "suck" air in, we will blow it up with a BVM, hence, no negative pressure.

If the pt is Cx, you may just want to offer a pillow of towel for them to "Cuddle" and splint it themselves.... Flail segments are extremely painful and Cx people will not let you near them.

I technically had a patient with a flail chest, I think. Thats the thing that sucks about being the basic on an ALS ambulance. Our guy had major crush injuries and needed to be at the trauma center, so as soon as he was extricated, we loaded him into the ambulance, and I drove to the trauma center. I asked my partner about it after the call, but its still not the same as being back there with the patient. Can't wait till I'm the medic in the back (2 more years...)

Anyway, the pt ended up having 6+broken ribs, and a small pneumo (my partner and the other medic in the back didn't realize he had a pneumo), but wouldn't even tolerate a pillow splint for his ribs.

A couple of points to bring up... concerning the posts where I have made certain lines stand out in bold.

First, concerning treatment with sandbags and IV bags, it is now considered to be outdated treatment. IV bags and sand bags (weight) placed on the chest can hinder the effort of breathing. Mobey brought up a treatment that is useable, a pillow or towel for the patient to use to splint their fractures themselves. I had not heard of this, but think it sounds like a good idea !

So, I will ask, since sandbags/IV bags are considered outdated now, what other splinting technique is recommended? When you find this technique, what would be an improper way to apply the splint, and why? (to give you a hint as to the improper application of the recommended splint, think of how its application would possibly hinder the effort of breathing)

Well as a BLS I will shoot at it

Flail chest is 3 or more ribs that are broken and only held in place by the ligaments and muscles of the chest wall.

How do I fix it? Pressure, Pressure, Pressure. Either with my hand, a sand bag, anything to keep pressure on the segment.

Short term concerns? Punctured lung, tension pneumo or pneumothorax. This is definatly an ALS call. I would load and go and contact my ALS via radio for a line of sight meet up. No playing around with this patient, we are looking at a multi system trauma and really in the field we have no way of telling the extent of the internal damage. If a Level 1 is too far out I would actually call for a bird!

Long Term? Well I would think pnemonia. I am not a doctor so diagnosis isnt in my SOP Kidding LOL I would think pain managment, surgical response to the flail, and infection at the site of the chest tube.

I have only seen one in my time as a BLS, caused by blunt force trauma from an unrestrained passenger and a dash board meeting during a telephone pole interview

In reference to pressure x3 and sandbags....see the above response.

It has been surmised that in trauma, we can predict the underlying injuries based on the mechanism of injury. With that in mind, mechanism + the area of the rib cage injured can give us great clues as to what injuries are present, before hemodynamic changes may be seen.

What other short term injuries may be suspected if the patient was struck in the rib cage? (think about what the ribs are attached to)

Pneumonia may very well be a complication that flail chest segment patient may have to endure. To help you think of some other 'pulmonary problems' the patient may experience, what complications will commonly present in the hospital/ICU? (it is possible to see these in the field too, but not common, in my experience)

I think another aspect for people to explore is signs/symptoms, and assessment findings you would expect to see, feel, or hear?

[Richard B the EMT]

I technically had a patient with a flail chest, I think. Thats the thing that sucks ...

I'll presume the pun was unintended. I'm re-posting to the Pundemonium string.

[tniuqs]

Mateo et all:

I have been standing back watching this thread not commenting ... yes mobey / rock shoes ..VERY atypical and unexpected. I have returned very recently from a Respiratory Conference and the "topic" of education for EMTs and Paramedics was discussed is some retail with a respiratory educator a Dana Oaks btw with similar status in the EMS world as the great educator Dr. B. Bledsoe. Dana Oaks (due to my background and some opinions felt that I too should get into education, possibly write a book for the EMS types as this is my first passion, although as rock shoes will be chuckling my editorial writing skills are less than a professional level

So the Flail Chest and "some" of the prior comments: I will make an attempt to provide some improved understanding as I have had to deal with a "few" these and without doubt some of the most difficult patients to manage.

Firstly bit of clarification we breath "in spontaneously inspiration" by generating a negative interthorasic pressure with the diaphragm (contracting) and the main mucles of respiration in the adult, in symphony the ribs and intercostal muscle (contracting)up and out this is called the "pump handle effect" hence physics all things attempting to equalise (as now ambient pressure) is higher

The Air Goes in, in EMS speak.

Note in this patient there is FORCED and accessory muscle usage further increasing WOB Work of Breathing.

Exhalation is passive in spontaneous breathing and even when ventilated as mobey refers, no offence these are NOT balloons ... pop a hole in a balloon and the party is over ... the good lord put a few safeguards in place for survival a thing called hysteresis, the lung by nature will not go flat like a tire. A comprehensive link here ... to put the YAWN of pulmonary mechanics into a better light and the complexity .. look at Lung elasticity Chest wall elasticity and FRC ... functional residual capacity. http://www.anaesthetist.com/icu/organs/lung/Findex.htm#lungfx.htm

5 to 6 ribs fractured in non communicating segments is "typically" the accepted definition of Flail Chest and also test question in Canadian National Final Respiratory exam's, no easy exam btw. That said 2 to 4 are still Flail but the integrity of the "pump handle effect" is no where near pronounced with morbidity mortality far lower.

Now just fer fun go back and look at this excellent "old" video and estimate the number of ribs possibly affected count down from angle of Louis thats rib 2 isnt it ? BUT this dude is in deep ca ca, he will eventually (due to extreme WOB) crap out, deterioration blood gasses then go outa whack and stop breathing.

HE will be Intubated !

The MOI is massive blunt force trauma is this pulmonary pathophyiology and traumatic forces is HUGE .. my guess is unbelted in MVA / MVC and steering wheel contact high speed solid object.

Look a tad deeper ... yes as stated a pneumo = air between the "Lung" and the "Chest wall" with a "Tension" many being that the air/ pressure in the wrong cavity will increase to the point of "crimping the aorta" The bandaging in the vid is most likely hiding the chest tube as with large Flail it will be assumed that "buddy does have a tension or soon will" because of the fractured ribs but then look a bit deeper as the MOI also affected "other" tissues underlying for example the Heart ! Traumatic Asphyxia is also in this toping the hit parade with this polytrauma patient.

Now remember that under every rib is a vascular supply, so hemo thorax is highly likely as well ... also note one can blled out with a costal artery tear in of itself ... oh yeah baby as is pulmonary contusion hugely complicating a high possibility of ARDS and If I were a betting man "post op" this patient is Tracheostomy and long term Ventilation ... add in VAP Ventilator Acquired Pneumonias.

A personal anecdote: Had an old farmer, he got run over with his own tractor (posterior Flail) lacerated a costal artery on asa (we didnt know this) and put enough pressure in retro peritoneal space to obstruct blood flow to Kidney . Yup my buddy Metro (a good tough man) died from this complication of renal failure and sorry bit of PSTD flashback there. One day he told me "hey don't worry Squinty" I have a first aid kit in my tractor and I could use it I "meaning me needed it" what a fighter he was. This was after weaning him off the ventilator and Trache plugging trials, its a very different look at the patients we deal with in EMS maybe a few hours contact then off we go ... as a bedside RRT and initially acute then the chronic long term care of people ... you develop a real relationship over the weeks / days / months. Funny thing how some people you will never forget RIP Metro .

More things to consider a bronchopulmonary leak/hole (major airway leaking air directly into chest cavity OMG these are so difficult to deal with in ICU sometimes requiring a Carlins Tube and bilateral Ventilation ... ie one lung ventilated independently of the other lung ... umm my brain is going to explode now.

But note well was anyone running around in that vid ? NO and why because buddy was waiting for a Thoracic Surgeon consult my bet and he already had bilateral chest tubes in situe because he IS going to OR and STAT like, some Chest Crackers will suture the broken ribs with wire ... some do not ... using PRESURE PRESSURE PRESSURE ... I like that btw Mateo.

I will leave that to next post, because presently there ARE some under used therapy's even BLS that could help to GET this patient to hospital .. but can't steal all the thunder from Mateo as I think I know where he is going .... ps good post btw

So once we Intubate as mobey refers ... we flip the entire physics of normal and negative pressure during inspiration pressures to positive NOW this ALSO affects the heart as the Right Ventricular Pressures increase, right ventricular filling pressures go up (in normal spontaneous ventilation LA filling pressures are "helpful" that said this ALL is increasing work of the heart, With the Lungs falling between the left and right side of the heart, this ultimately affects volume and refilling time to the Left Ventricular hence overall output is reduced and as is left atrial pressures (decreased) so no atrial kick .... Starlings law is affected.

All that said this is just with simple Intubation gets even more complex with Intubating the Flail Chest Patient, massive fluid infusion will not solve this problem its mechanical in nature but moderate volumes can help, even in virtual all Intubation(s)that said hypoxemia due to other injuries always a consideration but if hgb is steady state this can assist in diagnosis of other bleeding issues.

In the field in EMS we are still in the dark ages teaching putting a heavy bag IV or other to splint .. this is Korean War technology for BLS guys and girls "injured side down may can help" then again how can one do affective "C" spinal restriction ? OK agreed .. pillow well most of these injuries are decreased LOC so can try, and O2 absolutely ! Load and Go now that said ... careful you get to destination.

ALS decompress with big bore and bilateral, a must in my books, the patient will not even notice the pin prick, the big deal here is many Ditch Doctors cannot recognise that the caths have plugged out so keep checking the Cath for air movement. Ashermam chest valves (if you have those on car or a 3 sided seal with an open pneumo can frankly plug out quickly and then that open pneumo thorax becomes closed and results in a tension pneumothorax again life threatning, point I am making is dillegence and lots of revaluation en route.

A rapid hypotensive event PEA and or and brady arrest are some diagnostic signs ... dark humour there!

I will not comment on air transport but many times mobey, rock shoes and myself have to consider this is again a very serious complication with that damn Boyle's Law !

cheers for now.

[island emt]

Bless you IE, but did you get the part about letting the BLS and new ALS take some shots?

I did get the message Dwayne: Just wanted to put a few concepts out there for them to get started on. There is a lot more to dealing with this PT.

:-}

[tniuqs]

Seeing as no one has posted and picked up the obvious observational error I made, ps no bilateral chest tubes but appears he does have a radial art line in situe but why was the attendant taking a radial pulse then ?

OK a simple O2 mask? No pulse ox probe (obvious anyway)

No collar ?

What is that beeping in the back ground ?

Any other possible vascular injuries like possibility ie location, location, location ?

No one has tried to estimate the extent of the ribs segments involved ... and I gave a hint where to start.

How about a Cardiac Contusion ... any way you get a working indication or handle on that with the toys standard in the back of all trucks ?

BTW this has got to be very very old vid, no ECG monitoring ? HUH is this third world ER ?

In most cases in any modern ER, would there not be a dozen stickies on the patient already maybe a 12 lead or am I missing something ?

ALS or CCP guys ?

Would anyone RSI this patient ?

Any guesses on what and how this patient should be ventilated ?

Ventilation ?

Mode?

Maybe AC or CMV ?

Volumes in AC / CMV ?

Trigger Sensitivity set ?

or Pressure Control (so what PIP peak inspiratory pressures) ?

What respiration rate set initially ?

or PS = Pressure Support he does have respiratory drive .....

FiO2 ?

PEEP perhaps ? Splint with pressure from within ?

Still no answer from the BLS side of folks here ???

Would ANYONE assist with BVM ?

AND with a new toy they soon will have on most gut wagons, CPAP anyone ?

Ok say one uses CPAP, just how would one "titrate to effect" the CPAP levels in the field ?

hey I am willing to play or debate "many options" ... but if there is no willing to try.

My point back to original post re DANA OAKS ... in EMS its all black and white protocol driven monkeys (the gauntlet thrown btw)

In Medicine everything is shades of gray.

[mobey]

Ugh, I feel a beating coming on.....

OK, I'll start.

First obvioustly, ECG goes on, 12 lead, then continuous monitoring for rythm changes.

I will look for ECG changes including ST-Depressions, elevations (lower likelyhood), New onset BBB, persistant sinus tach (expect that anyway). Will also keep my eye on the voltage of the QRS and neck veins for tamponade signs.

Neck veins however, unless he is sitting up somewhat, not that reliable, and if bleeding is an issue, may not present. JVD could also point to tension pneumo developing.

ETc02 detector going on during initial assessment as well as SPo2.

There is a 99.99% chance this guy is going to get a needle into the effected side during transport. As long as I have at least 1 abnormal finding in my vital signs (SPo2, ETC02, BP). If he is not hypercarbic, hypoxic, or hypotensive, I will not do it since I know that would be sacraficing my licence. Again... not that it isn't a necissary treatment, but there are still some things the physicians want us to "react" to rather than "Proact". Decompression is one.

As far as the other unaffected side, depends on the mechanism. If I think it is involved, or if my first decompression does not give me the result I want, then ya.

RSI is definatly in his near future. I just dont have time to type it out right now.

I'll be back to this thread though

[tniuqs]

Ugh, I feel a beating coming on.....

OK, I'll start.

First obvioustly, ECG goes on, 12 lead, then continuous monitoring for rythm changes.

I will look for ECG changes including ST-Depressions, elevations (lower likelyhood), New onset BBB, persistant sinus tach (expect that anyway). Will also keep my eye on the voltage of the QRS and neck veins for tamponade signs.

Neck veins however, unless he is sitting up somewhat, not that reliable, and if bleeding is an issue, may not present. JVD could also point to tension pneumo developing.

ETc02 detector going on during initial assessment as well as SPo2.

There is a 99.99% chance this guy is going to get a needle into the effected side during transport. As long as I have at least 1 abnormal finding in my vital signs (SPo2, ETC02, BP). If he is not hypercarbic, hypoxic, or hypotensive, I will not do it since I know that would be sacraficing my licence. Again... not that it isn't a necissary treatment, but there are still some things the physicians want us to "react" to rather than "Proact". Decompression is one.

As far as the other unaffected side, depends on the mechanism. If I think it is involved, or if my first decompression does not give me the result I want, then ya.

RSI is definatly in his near future. I just dont have time to type it out right now.

I'll be back to this thread though

ah some feed back SWEET that said I do not know everything myself (was that my outside voice ? again)

Back to BLS crowd with Mobeys rolled up towel or pillow suggestion ... could one use Tape to hold it in place ?

No CPAP comments ?

cheers

[DwayneEMTP]

I thought the CPAP/splinting from within was intriguing, though it might never have occurred to me...I don't really know the answer, but as the pt isn't really going to live or die on my intuitive medicine today, I'm going to take a shot.

I'm no CPAP expert as I'm not really an expert on anything I guess, but I'm going to go with no on CPAP in the short term on this guy. It would depend on a lot of factor, BP/ECG/Pulse quality, etc. Intuitively it seems that the splint from within is a decent idea, but the splinting comes with the significant side effect of increased ITP (IntraThoracic Pressurebrev.Completely unsure if that is even a real abrev.) that could significantly complicate the other injuries and/or their side effects that are at least halfway likely with this guy.

Pneumo/Pneumo-Hemothorax, increase ITP certainly isn't going to do this guy any favors if they are present, and it's difficult to believe that they won't be present in some form. Ditto pericardial tamponade (When blood begins to leak into the sack around the heart).

On the flip side, if I don't see the electrical changes expected for tamponade, nor s/s of Hemo/Pneumo, and my b/p seems to be holding it's own, then it seems like it might be a good intervention? I'm not sure. The little angel on my shoulder says that this makes since, the little devil on the other is laughing his ass off knowing that I just stepped on my weenie..

Man, it's been a long time since I've posted here and though, "Holy shit..I hope I don't look like a complete idiot.." I like it!

I look forward to further conversation.

Dwayne

[tniuqs]

I thought the CPAP/splinting from within was intriguing, though it might never have occurred to me...I don't really know the answer, but as the pt isn't really going to live or die on my intuitive medicine today, I'm going to take a shot.

I'm no CPAP expert as I'm not really an expert on anything I guess, but I'm going to go with no on CPAP in the short term on this guy. It would depend on a lot of factor, BP/ECG/Pulse quality, etc. Intuitively it seems that the splint from within is a decent idea, but the splinting comes with the significant side effect of increased ITP (IntraThoracic Pressurebrev.Completely unsure if that is even a real abrev.) that could significantly complicate the other injuries and/or their side effects that are at least halfway likely with this guy.

Pneumo/Pneumo-Hemothorax, increase ITP certainly isn't going to do this guy any favors if they are present, and it's difficult to believe that they won't be present in some form. Ditto pericardial tamponade (When blood begins to leak into the sack around the heart).

On the flip side, if I don't see the electrical changes expected for tamponade, nor s/s of Hemo/Pneumo, and my b/p seems to be holding it's own, then it seems like it might be a good intervention? I'm not sure. The little angel on my shoulder says that this makes since, the little devil on the other is laughing his ass off knowing that I just stepped on my weenie..

Man, it's been a long time since I've posted here and though, "Holy shit..I hope I don't look like a complete idiot.." I like it!

I look forward to further conversation.

Dwayne

NOW where is chbare when you need a good debate ... sans quantum physics that is ! :devilish:

[mobey]

Getting back to where I left off....

I was about too RSI/RSS.

OK, so once I start a NRB, and splint this thing with a pillow (Not a circumfrential wrap as some may have been eluding too), I notice his SP02 raise from 91% to 95%. Some may be happy with this result. However, in watching the trending on my EtC02 go from 42-44-46-48.... Thats all I need, regardless of Sp02.

To be honest, he probably has had no pain control by this time, since I have pulled the trigger on RSI in my 1st 5min of meeting him. Just to stress it a little more.... The ETC02 went on at first contact, I want trending! One number is not enough for me in a resp patient, that is how I could determine the need for a critical intervention so fast in this presentation.

In all honesty... I do not want him breathing on his own at all, the more these ribs/chunks of sharp bone float around the better of a chance of shredding an intercostal artery and having another real problem.

So I would choose my drugs based on hemodynamic stability PRN.

Probably the standard Fentanyl/Midazolam. Succ to pass the tube, then rocuronium to continue paralysis.

CAREVent settings.... ugh jeez ummm... *Squint patch*

It is going to be whatever gets my Co2 near 40. Probably 600ml TV. RR 22 to start.... once excess C02 is blown off, rate can come down. I want to keep my volumes at the lower end to keep chest movement minimal. PEEP will be set at 5cm to replace physiological PEEP made at the vocal cords, and taken away by the tube, + 5cm extra (10cm total) for "internal splint".

This PEEP aint no game, I need to be really careful of hypotension, and REALLY aware of the pneumo possibility (more like inevitebility).

CPAP is not my first choice for a few reasons.

1) I have RSI

2) To give enough pain control, I will be sedating him past the "CPAP" limit. That is, he will not have enough drive to work positivly with the system.

3)Intubation is in his near future anyway.... proactive medicine is the way.

4)I would rather intubate him now, while he is still somewhat stable, I hate to wait till he's completely hypoxic.

Just thought of another neat BLS splinting idea,,,,

He needs spinaled, how bout a KED? Will assist with immobilization of the spine, and the flail segment.