Flail Chest Flail Chest Speaker: Dr S. N. Bhagirath Moderator: Dr Ravi Narayanan
Flail ChestFlail ChestSpeaker: Dr S. N. Bhagirath
Moderator: Dr Ravi Narayanan
A flail chest occurs when a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall.
This is usually defined as at least two fractures per rib (producing a free segment), in at least two ribs.
some definitions require three or more ribs in two or more places
Flail Flail ChestChest
Most Common – Vehicle Accidents (76%)
Second most common – Falls, especially in elderly population (weak, frail bones) (14%)
Third most common – blunt trauma in children, especially those with genetic conditions, eg. Osteogenesis Imperfecta.
Flail Chest - causesFlail Chest - causes
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.
Flail Chest – What is happening..?Flail Chest – What is happening..?
The flail segment will be pulled in with the decrease in pressure while the rest of the rib cage expands.
Flail Chest – What is happening..?Flail Chest – What is happening..?
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.
Flail Chest – What is happening..?Flail Chest – What is happening..?
However, a flail segment will also be pushed out while the rest of the rib cage contracts.
Flail Chest – What is happening..?Flail Chest – What is happening..?
Two TypesFlail Chest – TypesFlail Chest – Types
Since the flail segment moves in an opposite direction to rest of the chest wall
Flail Chest – What is happening..?Flail Chest – What is happening..?
Paradoxical BreathingParadoxical Breathing
Pain
Flail Chest – ImplicationsFlail Chest – Implications
Pneumothorax, Hemothorax
Mediastinal Flutter
Pulmonary Contusion Respirato
ry Failure
Flail Chest – DiagnosisFlail Chest – Diagnosis Clinical examination for bruises,
paradoxical movement of flail segment.
Chest X – Ray
Computed Tomography
Flail Chest – ManagementFlail Chest – Management Analgesia.
Intubation and Ventilation.
Chest Tube Insertion
Rib Fracture Fixation
Flail Chest – ManagementFlail Chest – ManagementAnalgesia.MainstayOpioid Analgesics (risk of respiratory depression)NSAIDsThoracic or high lumbar Epidurals with or without Opioid additives.Posterior rib blocks (lasts upto 24 hours)Instillation of L.A. into pleural space through ICD (controversial)
Flail Chest – ManagementFlail Chest – ManagementIntubation & Ventilation.Rarely indicatedIndicated for hypoxia due to pulm. contusions.Double lumen tracheal tube. each lumen connected to a different ventilator. each lung may require drastically different pressures and flows to adequately ventilate.
Flail Chest – ManagementFlail Chest – ManagementChest Tube Insertion
To treat hemothorax
To treat pneumothorax
Flail Chest – ManagementFlail Chest – ManagementRib Fracture FixationUsually not requiredPreferred choice before intubation & ventilation.
Flail Chest – ManagementFlail Chest – ManagementPhysiotherapyTo aid better drainage of secretionsTo rebuild musculatureTo reposition chest wallCoughing exercisesResistance exercisesTrunk exercises
Flail Chest – ManagementFlail Chest – ManagementRehabilitation12 week outpatient program for at least 3 days a week
patient should be seen for 30–45 minutes a day after a 5-10 minute warm up session.
After discharge, patient should be given an exercise regimen to be performed at home.
Flail Chest – OutcomeFlail Chest – Outcome
Mortality Rate of flail chest ranges from 10-25%.
Ventilation has little effect on outcome
Flail Chest – VideoFlail Chest – Video
Flail Chest – ReferencesFlail Chest – References Millers Anesthesia Morgan’s Clinical Anesthesia Athanassiadi, Kalliopi, Michalis Gerzounis, Nikolaos
Theakos. Management of 150 flail chest injuries: analysis of risk factors affecting outcome. European Journal of Cardio-thoracic surgery 26. (2004).
Wikipedia www.trauma.org Blunt thoracic trauma: flail chest, pulmonary
contusion, and blast injury Sandra Wanek, MD, John C. Mayberry, MD, FACS
Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma 1994;37(6):975 – 9.