Flail chest

Last Updated on by FRCEM Intermediate

Overview

A flail chest is defined as fractures of 2 or more ribs in 2 or more locations. This results in a segment of the chest wall that is no longer in continuity with the rest of the thoracic cage. Paradoxical movement results, the segment moves inwards on inspiration as the rest of the chest expands and outwards on expiration as the rest of the chest deflates.

Clinical features

  • Chest pain
  • Respiratory distress
  • Boney crepitus
  • Paradoxical chest wall movements of the affected segment (not apparent if positive pressure ventilation applied)

Investigations

  • SpO 2 on pulse oximetry.
  • ABG — the combination of hypoxia and respiratory acidosis indicates severe respiratory compromise.
  • CXR will demonstrate fractures and associated injuries (eg pulmonary contusions, pneumothorax, haemothorax)

Management

  • Provide high flow O 2 and treat associated life-threatening problems.
  • Analgesia — paracetamol 1g qid po, NSAIDs if not contraindicated, titrated opiates IV (e.g. fentanyl 25 micrograms q5min prn IV). Early use of regional anesthesia (intercostal nerve blocks, paravertebral block, epidural anesthesia) due to risk of respiratory depression.
  • Contact the anesthetist team and carefully consider the need for immediate or urgent tracheal intubation with IPPV.

 

Chest injury Read:

Trauma! Chest Injuries I

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