Flail chest. Wanna see?

[tniuqs]

tniuqs, on 05 November 2010 - 07:44 PM, said:

Also, I was told in class not to use sandbags, IV bags or anything heavy due to the fact it will cause respiratory difficulty or make it worse. Are sandbags still an accepted practice, or is it best to use bulky dressings?

Dont know how you did that thats NOT what I stated at all that was someone else .

Agreed with Dwayne this editor sometimes sucks.

What I did say WAS :

Back to sand bags OK ... So do this simple test Go "Find a 10 lb sand bag" put it on your chest (no pain, no injury) and breath on your back for 15 minute's, then go watch TV ... just what will this do to WOB work of breathing (if spontaneously) then YOU tell me what YOU think ... ps if any MD asks why you did NOT use a Sandbag on a FLAIL ... ask him to do the same "test"

Richard see where I going with this ??? even Old Med Directors can be trained to do new "tricks"

Current NYS DoH policies hold as NO weight, such as sandbags or IV bags, but use bulky dressings.

My unsubstantiated belief re bulky dressings is not so much for stabilization, but as cushioning and/or protection. AS belief, don't hold to it until and unless your medical control and state/provence DoH agrees, as I could be wrong.

[tniuqs]

I stand by my statements. Not all flail chest patients need intubation. In fact, we open a new can of worms when we intubate. The complications can be as bad or worse than the condition that led to the intubation. However, I never said do not intubate if it is needed, I said tunnel vision is possible and not every patient will need intubation.

Just a physics point, most everything we deal with in science and medicine is theory. However, if said theory explains the physical world accurately, I believe it until something more accurate comes along. Quantum mechanics, explains much of the physical world. We have used it to predict the bonding and thus creation of new medications, we used it to create wondrous diagnostic technology such as MRI, we used it to push foreword into the technology revolution and even the most nonintuitive aspects of it explain how flash drives and solid state hard drives work. I agree, that how we use the predictions of the theory is very important. In fact, I know very little of how to work through quantum mechanical calculations, but understand the basic implications of the solutions.

Understanding the theory then Good Observation with a Questioning mind, moreover testing those chemical reactions (although most medications come from nature already) Observation is medicine this is how diabetes was discovered (Banting and Best) observing removing pancreas in dogs ... but ants were attracted to the urine ???

Pulse Oximetry and unknown lab worker (I am certain as the guy that actually invented velcro is STILL POOR (I digress) was doing non invasive, non destructive testing on cement and using light absorption ... well he cut his finger and bleed on test material .... next thing you know its a Vital Sign.

Take care,

chbare.

[chbare]

Looking at the OP, I understood that this scenario was a more general flail chest discussion where we are discussing the video in broad terms or "gross" terms is what I believe was originally stated. Regarding the video, I have no answer. I do not know if I would intubate the patient or not.

Take care,

chbare.

[DwayneEMTP]

Looking at the OP, I understood that this scenario was a more general flail chest discussion where we are discussing the video in broad terms or "gross" terms is what I believe was originally stated. Regarding the video, I have no answer. I do not know if I would intubate the patient or not.

Take care,

chbare.

You're absolutely right. And that was a weakness in my presentation. I'd meant to imply that I had no information that we couldn't gleen from the video but didn't want to limits the 'what if' possibilities for exploration...

I'm not terribly strong at the scenario thing, but I'm practicing! Thanks for continuing to participate.

Dwayne

[zzyzx]

I had this patient on my last shift. No, not this same patient, but my patient's flail chest looked exactly like that. Very dramatic and hard to miss! In 8 years on an ambulance, this was the first time I've seen one. He was wearing his seat belt, and you could see a bruise from the belt running up along his chest.

He did not get intubated in the ER, and he avoided a chest tube as well, at least while he was in the ER. The CT showed a pulmonary contusion and a bit of a hemothorax.

[tniuqs]

Well follow up for us would you ?

It would be interesting to see how your patient progresses.

cheers

[PCP]

I will take a kick at the can. I am not a ALS paramedic so there is not going to be any 12 leads or tubes happening with me.

A flail chest is where three or more adjacent ribs fracture in two or more places. I was lucky enough during my precepting time to see a pt. that had a flail chest. His flail segmant was on his upper back which was caused by a fall and hitting a lawn chair. Any ways back to the questions.

I am going to assume this pt in this video was in a MVA, riding a motorcycle crashed and hit the handle bars or something that was stationary that would cause blunt force trauma like that.

Primary and short term concerns: course pneumo., tension pneumothorax, spinal concerns, hemothorax, paricardial Tamponade, myocardial contusion,Myocardial Aneurysm or Rupture, Traumatic Aneurysm or Rupture of the Aorta, breathing concerns for sure would need to bag this pt., want to look for any signs or symptoms of internal bleeding from a lacerated spleen or liver. By the look of that fellow there would and could be multiple things wrong with him and that could go wrong within minutes or hours.

Long term concern is a Pulmonary Embolism may occur, pneumonia, ummm cant really think of anything at this moment as it is three in the morning.

I would for sure be loading and going with treatment enroute, notifying the hospital what I am bringing in and my ETA. This is a trauma pt and the "Golden Hour" is very important for this fellow and he needs surgery. There is not much I can do for him other then what I will do for my treatment.

TX- first of all make sure he has a patent airway, check the breathing fix what I can in the breathing (BVM, splint the flail sagment with as many abdominal pads as I may need folded up covering the entire flail segmant and start taping it down. If the flail sagment is large and is going to take too much time to apply the pad and tape I would a pillow and have them hold it there for support or use a first responder to hold for the pt. If spinal immobilization was not required I would place my pt. on the side of the injury. while in tranport I would be starting an IV on the guy and depending if the BP is below 90mmHg I would run my line at TKVO or I would bolus him 500ml at a time and auscultate the bases of the lungs before and after every bolus checking for pulmonary edema. in between boluses if multiple boluses where needed, I would be running through my head to toe again looking for any other injuries that may have been missed while on scene.

Just by looking at the guy on the video I think I would be calling for a medivac for this guy, as our hospital where I work would only be able to stabilize him and he would be flowen to Vancouver, Nanaimo, or Victoria where they could do Surgery for him.

Hope I was not too far with my answers. I must say great post!

[CSAR_MEDIC]

I've seen it twice, and once was almost a duplicate to the video, the second, as Mobey stated, just looked like a strange swelling under the pectoris muscle. I'm guessing due to splinting secondary to spasm, though that didn't occur to me at the time. My official working diagnosis for that injured part was, "Wow, that's weird, better keep an eye on it." I was told of the diagnosis later at the ER.

Can you take a run at the rest of the questions FP? I'm proud, though not surprised to see you being the first to jump in.

And Mike, that Pararescueman technical specialist ninja to you... Doctors only wish they could be so macho. (Some AF guy is going to see my badge and beat the shit out of me...I just know it.)

Dwayne

As a fellow Pararescueman technical specialist i would agree this is an amazing video, I showed it off at our camp and no one was interested because everyone claimed they have seen one before and treated it (Bravo Sierra IMHO) I would really like to see more videos like this on here as well as some instructional videos as well. Forums like this can only help elevate our profession.

my .02

[codesurfer]

As a soon to be ALS provider and a new member I guess I'll take a stab at this.....

What is flail chest?: I think it's defined as 3 or more ribs broken in 2 or more places.

What caused it?: Since it is unknown I am going to go with some sort of blunt trauma.

What are your primary short term concerns?: Hypoxia. Possible ventilation issues. Cardiac compromise with its proximity to the heart (maybe some type of cardiac contusion). Any other issues due to the injury, I willing to say that this is probably not an isolated injury unless someone used a baseball bat.

Longer term concerns?: No idea.

Load and go/stay and play? Why?: I would call this a load and go. Mainly because if you've got an injury like that to the chest I am going to assume you've got a serious mechanism and there are going to be some other injuries involved. This may be distracting you from some other serious issues the dude is having.

Treatment?: "bulky dressing". I know that's how your supposed to treat this. But have always been unsure as why. Do you really want to push the flail segment back down? Wouldn't that compress lung tissue and possibly reduce lung expansion? If you need to start BVM ventillations couldn't that increase your chances of some sort of barotrauma? Honestly if I got this man tomorrow...I would put him on a backboard, start a large bore IV or two depending on vitals, throw on a NRB at 15 liters, place him on the monitor, and roll to the ER.

[DFIB]

Would anyone be concerned about a possible cardiac Tamponade in this patient? I would look for Beck’s Triad.

At least his breathing is easy to count while the truck is moving.