1Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 21

Flail Chest

2Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 21-1. Flail chest. Double fractures of three or more adjacent ribs produce instability

of the chest wall and paradoxical motion of the thorax. Inset, Atelectasis, a common

secondary anatomic alteration of the lungs.

3Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Anatomic Alterations of the Lungs

Double fracture of numerous adjacent ribs

Rib instability

Lung restriction

Atelectasis

Lung collapse (pneumothorax)

Lung contusion

Secondary pneumonia

4Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Etiology

Motor vehicle accident

Falls

Blast injury

Direct compression by a heavy object

Industrial accident

5Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Overview

of the Cardiopulmonary Clinical Manifestations

Associated with

Flail Chest

The following clinical manifestations result from the

pathophysiologic mechanisms caused (or activated)

by Atelectasis

Pneumonic consolidation

6Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

7Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

8Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Data Obtained at the

Patient’s Bedside

9Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

The Physical Examination

Vital Signs Increased respiratory rate (tachypnea)

• Tachypnea occurs because of the following: Stimulation of peripheral chemoreceptors

(hypoxemia)

Paradoxical movement of chest wall—see Figure

21-2 and Figure 21-3.

10Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

The Physical Examination (Cont’d)

Vital Signs (Cont’d) Decreased lung compliance/increased ventilatory

rate relationship

Activation of the deflation receptors

Activation of the irritant receptors

Stimulation of the J receptors

Pain/anxiety

11Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 21-2. Lateral flail chest with accompanying pendelluft.

12Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 21-3. Venous admixture in flail chest.

13Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

The Physical Examination

Vital Signs (Cont’d) Increased

• Heart rate (pulse)

• Blood pressure

14Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

The Physical Examination

Cyanosis

Chest Assessment Findings Diminished breath sounds—on both the affected

and the unaffected sides

15Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Data Obtained from

Laboratory Tests and Special

Procedures

16Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Pulmonary Function Test FindingsModerate to Severe

(Restrictive Lung Pathophysiology)

Lung Volume & Capacity Findings

VT IRV ERV RV VC

N or

IC FRC TLC RV/TLC ratio

N

17Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Arterial Blood Gases(Mild to Moderate Flail Chest)

Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis)

pH PaCO2 HCO3 PaO2

(slightly)

18Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

PaO2 and PaCO2 trends during acute alveolar hyperventilation.

19Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Arterial Blood Gases(Severe Flail Chest)

Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis)

pH PaCO2 HCO3 PaO2

(Slightly)

20Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

PaO2 and PaCO2 trends during acute or chronic ventilatory failure.

21Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Oxygenation Indices

QS/QT DO2 VO2 C(a-v)O2 O2ER SvO2

N (Severe)

22Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemodynamic IndicesSevere Flail Chest

CVP RAP PA PCWP CO SV

SVI CI RVSWI LVSWI PVR SVR

23Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Radiologic Findings

Chest radiograph Increased opacity

Rib fractures

Increased density on the affected side

24Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 21-4. A, Chest X-ray film of a 20-year-old female with a severe right-sided flail

chest. B, Close-up of the same X-ray film, demonstrating rib fractures (arrows).

25Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Respiratory Care Treatment

Protocols

In mild cases:

Medication for pain and routine bronchial

hygiene

Severe cases

Volume-controlled ventilation with PEEP 5 to 10 days usually adequate for sufficient bone

healing

26Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Respiratory Care Treatment

Protocols (Cont’d)

Oxygen Therapy Protocol

Lung Expansion Therapy Protocol

Mechanical Ventilation Protocol