Miguel S.

Datijan III
Student Number: 11-2-89078

October 3, 2014
BSN 4th Year

REPORT ON FLAIL CHEST

FLAIL CHEST
Severe blunt injury to the chest continues to be one of the leading causes of
morbidity and mortality in both young and old trauma victims. [1] Flail chest is one of
the worst subset of these injuries and is likely the most common serious injury to
the thorax seen by clinicians.
Multiple

care patterns and treatment modalities have

emerged, many based on anecdotal clinical
observation and evidence. Within the last 20 years,
more rigorous scientific methods have been
applied to the problem of flail chest, in both
the clinical setting and laboratory. More
advanced radiologic work-up with multislice
computed tomography (MSCT) scanners is
increasing the frequency of diagnosis of this
problem. This article reviews the most salient
data of the recent literature and discusses
some of the diagnostic and treatment options
that are now available in the treatment of flail
chest.

ETIOLOGY
Flail chest requires significant blunt force trauma to the torso to fracture the ribs in multiple areas. Such trauma
may be caused by motor vehicle accidents, falls, and assaults in younger, healthy patients. Flail chest is an
indicator of significant kinetic force to the chest wall and rib cage, but it may also may occur with lesser trauma
in persons with underlying pathology, including osteoporosis, total sternectomy, andmultiple myeloma, as well
as individuals with congenital absence of the sternum.
SIGNS AND SYMPTOMS
Two of the symptoms of flail chest are chest pain and dyspnea.[7]
Diagrams depicting the paradoxical motion observed during respiration with a flail segment

The characteristic paradoxical motion of the flail segment occurs due to pressure changes associated with
respiration that the rib cage normally resists:
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.
The flail segment will be pulled in with the decrease in pressure while the rest of the rib cage expands.
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.
However, a flail segment will also be pushed out while the
rest of the rib cage contracts.
The constant motion of the ribs in the flail segment at the site of the
fracture is extremely painful, and, untreated, the sharp broken edges
of the ribs are likely to eventually puncture the pleural sac and lung,
possibly causing a pneumothorax. The concern about "mediastinal
flutter" (the shift of the mediastinum with paradoxical diaphragm
movement) does not appear to be merited.[8] Pulmonary contusions
are commonly associated with flail chest and that can lead
torespiratory failure. This is due to the paradoxical motions of the
chest wall from the fragments interrupting normal breathing and chest
movement. Typical paradoxical motion is associated with stiff lungs,
which requires extra work for normal breathing, and increased lung
resistance, which makes air flow difficult.[9] The respiratory failure from
the flail chest requires mechanical ventilation and a longer stay in an
intensive care unit.[10] It is the damage to the lungs from the flail
segments that are life-threatening.

PATHOPHYSIOLOGY

In an adult, a transfer of significant kinetic energy in blunt trauma to the rib cage or
a crushing rollover injury is the most frequent cause of flail chest. In children, who
have a more compliant chest wall, flail chest is observed with lower frequency than
injury to the underlying structures, including the lungs, heart, and mediastinal
structures.
RELEVANT ANATOMY
The chest wall is inherently stable, with 12 ribs attaching posteriorly to the spinal column and anteriorly to the
sternum. Intercostal muscles with fascial attachments, coupled with other muscle groups, including the
trapezius and the serratus groups, add further strength to the bony cage around the thoracic organs. The arch
design of the ribs allows for some flexing, more so in children than adults, which can absorb small amounts of
blunt kinetic energy. Crush or rollover injuries, especially with heavy objects or significant deceleration injury
commonly breaks a rib in 1 position, but only a significant impact breaks a rib in 2 or more positions.
DIAGNOSTIC PROCEDURES
Pulmonary contusions are rarely diagnosed on physical examination. The mechanism of injury may suggest
blunt chest trauma, and there may be obvious signs of chest wall trauma such as bruising, rib fractures or flail
chest. These suggest the presence of an underlying pulmonary contusion. Crackles may be heard on
auscultation but are rarely heard in the emergency room and are non-specific.

Severe bilateral pulmonary contusions may present with hypoxia - but more usually hypoxia develops as the
pulmonary contusions blossom or as a result of subsequent ARDS.
Chest X-ray
Most significant pulmonary contusions are diagnosed on plain chest X-ray. However the chest X-ray will often
under-estimate the size of the contusion and tends to lag behind the clinical picture. Often the true extent of
injury is not apparent on plain films until 24-48 hours following injury.

Pulmonary Contusion
Admission CXR

Pulmonary Contusion
24 Hours

Computed Tomography
Computed tomography (CT) is very sensitive for identification of pulmonary contusion, and may allow
differentiation from areas of atelectasis or aspiration. CT also allows for 3-dimensional assessment and
calculation of the size of contusions. However, most contusions that are visible only on a CT scan are not
clinically relevant, in that they are not large enough to impair gas exchange and do not worsen outcome.
Nevertheless, CT will accurately reflect the extent of lung injury when pulmonary contusion is present.

TREATMENT

Treatment of the flail chest initially follows the principles of advanced trauma life
support. Further treatment includes:
Good analgesia including intercostal blocks, avoiding narcotic analgesics as
much as possible. This allows much better ventilation, with improved tidal
volume, and increased blood oxygenation.
Positive pressure ventilation, meticulously adjusting the ventilator settings to
avoid pulmonary barotrauma.
Chest tubes as required.
Adjustment of position to make the patient most comfortable and provide
relief of pain.
Aggressive pulmonary toilet
Surgical fixation can help in significantly reducing the duration of ventilatory
support and in conserving the pulmonary function. [15]
A patient may be intubated with a double lumen tracheal tube. In a double lumen
endotracheal tube, each lumen may be connected to a different ventilator. Usually
one side of the chest is affected more than the other, so each lung may require
drastically different pressures and flows to adequately ventilate.