0071643192.pdf

Flail Chest

Flail chest is defined by the presence of fractures in more than one location

on each of three or more adjacent ribs causing a free floating segment of ribs

and an unstable chest (see Figure 3.11).

SYMPTOMS/EXAM

■ Flail segment may move discordant with the rest of the chest (in with inspi-

ration and out with expiration).

■ Significant flail chest is often associated with tachypnea and hypoxia.

DIAGNOSIS

■ CXR or CT scan may reveal multiple rib fractures.

■ Flail may only be minimally apparent immediately after injury and becomes

more apparent as lung compliance worsens, necessitating greater inspiratory

effort.

TREATMENT

■ Primary treatment is analgesia, coughing and chest physiotherapy, and

preventing fluid overload and consequent lung edema. These measures

maximize tidal volumes and help prevent hypoxia and PNA.

■ Do not wrap the chest as this inhibits chest expansion.

■ Intubation and ventilationmay be needed in patients with shock, three

or more associated injuries, head injury, underlying pulmonary disease,

eight or more rib fractures, age >65 years, or PaO 2 <80 mmHg on supple-

mental O 2.

■ Early ventilatory support can help reduce mortality of severe flail chest

from 69% down to 7%.

COMPLICATIONS

Anticipate patient fatigue because of decreased mechanical efficiency causing

increased work of breathing.

TRAUMA

FIGURE 3.11. Diagram of flail chest.

(Reproduced, with permission, from Doherty GM. Current Surgical Diagnosis and Treatment,

12th ed. New York: McGraw-Hill, 2005:214.)

In patients with flail chest,

underlyinglung contusionis

the main cause of hypoxemia.