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The treatment of flail chest injuries continues to be search Unit from the operating room. Serial blood gas
a difficult clinical problem. Tracheal intubation and analyses were performed on all patients.
internal pneumatic stabilization with volume-cycled Prior to October 1973, all patients with flail chests
ventilators have supplanted external stabilization of diagnosed on admission were ventilated with a volume-
cycled respirator until the flail segment had stabilized.
the flail segment as the treatment of choice. The
After October 1973, patients were not routinely ventilated.
mortality rate, however, remains high despite this
Mechanical ventilation was reserved for those patients
change in therapy [I-81. In addition, the morbidity who, after initial evaluation and treatment in the emer-
has increased because of complications caused by gency department, manifested clinical respiratory distress.
tracheal intubation and mechanical ventilation. Criteria of clinical respiratory distress were tachypnea,
These results have led at least one investigator to dyspnea, air hunger, and agitation, with an arterial PO2 on
question the routine use of ventilatory support in the room air of less than 60 mm Hg, or a PC02 of greater than
treatment of flail chest [9]. We have treated selected 60 mm Hg. All other patients were treated with chest
patients without mechanical ventilation during the physiotherapy and either intercostal nerve blocks or epi-
past year and retrospectively compared them to a dural anesthesia. Mechanical ventilation was provided by
similar group of patients who were treated with me- the Bennett MA-l volume-cycled respirator. All patients
were treated by the same nursing staff and staff sur-
chanical ventilation.
geons.
Using the criteria of clinical respiratory distress with an
Material and Methods arterial PO2 of less than 60 mm Hg or a PC02 of greater
The records of all patients admitted to the Trauma than 60 mm Hg, all patients were retrospectively assigned
Service, Naval Hospital, San DKgo, with the diagnosis of to one of three groups: group I, “appropriately” ventilated;
flail chest from March 1972 to July 1975 were reviewed and group II, “inappropriately” ventilated; group III, non-
comprise the series. The diagnosis of flail chest was based ventilated. Patients who were ventilated only during op-
upon the presence of paradoxical movement in a segment eration and extubated before stabilization of the flail seg-
of chest wall. Initial evaluation in the emergency depart- ment were included in group III.
ment included complete physical examination, chest x-ray, These groups iere compared with respect to the fol-
and arterial blood gas analysis. All patients found to have lowing variables: age, number of ribs fractured, number of
hemothorax or pneumothorax underwent tube thoracos- associated injuries, number of days of respiratory support,
tomy in the emergency department. Patients whose asso- complications, and mortality rate. Means and standard
ciated injuries did not require an operation were admitted errors of the mean were calculated and differences between
directly to the Trauma Research Unit. Those patients re- groups were assessed using Student’s t test, analysis of
quiring an operation were transferred to the Trauma Re- variance, and the chi square distribution. Significance was
attributed to p < 0.01.
Results
From the Trauma Reeearch Mt. Naval RegIonal Medical Center, San Dii,
California. This work was supported in part by ONR Contract N-6-
484972-25925. The opinions or assertions expressed herein are those of
The forty-two patients (40 males, 2 females)
the author and are not to be construed es official or as reflecting the views ranged in age from eighteen to eighty years (mean
of the Navy Department or the naval service at large.
age, 43 years). Thirty patients were injured in auto-
Reprint requests should be &kessed to Steven R. Shackfod, LT MC USN,
Tram Research Unit, Naval Regional Medical Center, San Diego, California mobile accidents, four were injured in falls, three
92134.
Presented at the Twenty-Eighth Annual Meeting of the Southwestern
were struck by automobiles, two were assaulted, one
Surgical Congress, Houston, Texas, May 3-6, 1976. was injured in an airplane crash, and one sustained
No. of
Twe Patients
Orthopedic
Axial fractures 12
Other (acromioclavicular separations, pelvic 17
fractures, etc)
Abdominal (requiring operative intervention)
Liver Injuries 2
Splenic Injuries 4
Neurologic
Concussion 15
Subdural hematoma 1
Peripheral nerve injury 2
Vascular
Aortic arch injury 2
Peripheral arterial injury 2
Figure 1. Retrospective assignment of patients with flail
chest /njuf/es to treatment groups.
TABLE II Comparison of Treatment Groups
hypoxia rather than hypercarbia determined the TABLE III Review of 10 Year Experience with
the accumulation of tracheobronchial secretions and function. This allowed division of patients into three
the development of atelectasis. groups: “appropriately” ventilated; “inappro-
Initial hypoxemia is a good indicator of the need priately” ventilated; and nonventilated. Admission
for mechanical ventilation, but additional factors PO2 in the “appropriately” ventilated patients was
must be considered. If hypoxemia can be corrected significantly lower than in the other two groups be-
by administration of supplemental oxygen, the V/Q cause the former were admitted with respiratory
abnormality is minor and mechanical ventilation can distress and hypoxemia. Significantly more compli-
be avoided. Likewise, correction of mechanical cations occurred in the ventilated groups than in the
problems such as tension pneumothorax or hem- nonventilated. Treatment-associated complications
othorax may resolve the hypoxemia. Hypoxemia were more frequent in the ventilated groups. Because
persisting after correction of mechanical factors and of these findings, we believe that mechanical venti-
administration of supplemental oxygen indicates lation should be used in the treatment of flail chest
severe abnormalities in gas exchange and mechanical injuries only for significant pulmonary dysfunction
ventilation should be instituted. and not for the purpose of stabilizing the chest wall.
Our patients in group III demonstrate that selected If respiratory support is required, it should be dis-
patients do well without mechanical ventilation or continued when normal gas exchange has been re-
any other means of chest wall stabilization. We stored.
treated eleven patients with analgesia and aggressive
pulmonary toilet without mortality or significant References
morbiditv. Intercostal nerve blocks or continuous
1. Reid JM, Baird WLM: Crushed chest injury: some physiological
epidural anesthesia was instituted early in all pa-
disturbances and their correction. 8r Med J 1: 1105,
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anxiety and allowed the patient to cough and tolerate 2. Perry JF, Galway CF: Factors influencing suvival after flail chest
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ventilatory support. Trinkle et al [9] recently re-
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Holmstrom FMG: Management of flail chest without me-
Mechanical ventilation has an important place in chanical ventilation. Ann Thorac Surg 19: 355, 1975.
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Am J Surg 90: 517, 1955.
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14. Carlisle BB, Sutton JP, Stephenson SE: New technique for
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Retrospective analysis of forty-two consecutive new method of treatment with continuous mechanical hy-
patients with flail chest injuries admitted to the perventilationto produce alkalotic apnea and internal
Trauma Research Unit of the Naval Regional Med- bneumatic stabiliz&ion. J Thorac Surg 32: 291, 1956.
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ment. The actual need for ventilatory support in 17. Sarnoff SJ, Gaensler EA, Maloney JV: Electrophrenic respi-
ration:the effectiveness of contralateral ventilation during
these patients was determined by analyzing their activity of one phrenic nerve. J Thorac Surg 19: 929,
records for evidence of significant pulmonary dys- 1950.