The Management of Flail Chest - Tata

8/9/2019 The Management of Flail Chest - Tata

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Brian L. Pettiford, MD, James D. Luketich, MD,Rodney J. Landreneau, MD

Thorac Surg Clin ! "#$$!% #&'((


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Thoracic trauma is )uite common in the*S

Thoracic trauma accounting for + #$

of all trauma death in the *SMost of thoracic in-ury sustain in motor

ehicle crash is /lunt in nature

Blunt InjuryForces

Compression

Shearing Blast


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The common result of com0ressie in-uryto the thoracic cage is ri/ fracture

1lail chest occurs in $ of thoracic

trauma cases, 2ith mortality rate/et2een $3&


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Schematic of 4ail chest 0hysiology. "1rom May/erry J, Trunkey D. Thefractured ri/ in chest 2all trauma. Chest Surg Clin 5 6m 77!8!9#&(8

2ith 0ermission.%


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Re)uirement 9 :n-ury mechanism 9 Motor ehicle crash

Physical e;amination▪ Parado;ical motion

▪ Seere chest 2all 0ain

▪ Res0iratory insu 6/dominal CT Scan


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Primary focus 9 6de)uate entilationmanagement

Mid 7&$s :ntermiten 0ositie0ressure entilation 2as st used

Late 7?$s3early 7!$s

tracheostomy+ mechanical entilation

Mid 7!$s com/ination of 4uid

restriction, corticosteroid, aggressie0ulmonary toilet,> 0ain killer


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6t 0resent96dmission to trauma :C*

6ggressie 0ulmonary toiletPain control


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6de)uate 6nalgesia fasilitates0ulmonary toilet an dearly mo/ili@ation

.Sistemic A0ioid#.Control anasthesia 2ith continuos

infusion(.Bu0iacain intercostal nere /lock

.0idural analgesia&. Thoracic 0araerte/ral /lock?.5S:D


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igh mortality rate is 0rimarily caused/y associated in-ury

:n-ury Seerity Score ":SS% has /eenuseful to determine the outcome

:ndication of arly Mechanical Eentilator9 :SS F #(

ead or truncal organ in-ury Shock on admission

Blood transfusion 2ithin the st # hour


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:ndication9 Ather intrathoracic in-ury 2hich re)uire

thoracotomy

*nsuccessfully 2eaned from mechanicalentilator

Seere chest insta/ility

Persistent 0ain secondary to malunionfracture

PersistentG0rogressie loss of 0ulmonaryfunction


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"6% Chest radiogra0h of Lu)ue rod H;ation of 0osterolateral 4ail cheststa/ili@ed 2ith ortho0edic e;ternal H;ation deices. "B% Plain Hlma00ro;imately ( months after deice remoal. "1rom Landreneau R,

inson J, a@elrigg S, et al. Strut H;ation of an e;tensie 4ail chest. 6nn Thorac Surg 778&9!8 2ith 0ermission. Co0yright 77, The


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"6% Chest radiogra0h sho2ing olume loss and ri/ cage deformity aftermulti0le left3sided ri/ fractures. "B% Posto0eratie Hlm at monthfollo2ing metallic strut 0lacement. 5ote im0roed olume in the left

hemithora;. "1rom aasler I. A0en H;ation of 4ail chest after /lunttrauma. 6nn Thorac Surg 77$879778 2ith 0ermission. Co0yright


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Judet Struts and a00lication 0liers. "1rom Tanaka , ukioka T, amaguti , et al. Surgical sta/ili@ation of internal 0neumaticsta/ili@ationK 6 0ros0ectie randomi@ed

study of management of seere 4ail chest 0atients. J Trauma#$$#8!#78 2ith 0ermission.%


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Schematic of ste0s through ?for (.&3mm aceta/ularreconstruction 0late H;ation

along each side of the fracturesite. "1rom Ayar@un J, Bush 6,McCormick JR, et al. *se of (.&3mm aceta/ular reconstruction0latesfor internal H;ation of 4ail chest

in-uries. 6nn Thorac Surg778?&9!#8 2ith 0ermission.


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Disadatage of the metal 0rothesis9 :t a/sor/s most of the stress directed

to2ard the aected ri/, resulting indelayed 2ound healing

The rigidity e;ceeds that of theaected ri/s may result in scre2loosening, 0late dislocation, orchronic chest 2all 0ain, re)uiringsu/se)uent remoal


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6/sor/a/le 0olyactide 0olymer 0lates >scre2com/ine 2ith cerclage Promotes fracture healing

Preclude of the need for 0rothesis remoal

Long term /eneHt of surgicalmanagement

include the restoration of normal chest2all geometry and im0roe 0ulmonaryfunction testing


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Chest Hlms made "6% 0reo0eratiely,"B% immediately 0osto0eratiely, and

"C% year 0osto0eratiely. "1romAyar@un J, Bush 6, McCormick JR, et al.*se of (.&3mm aceta/ularreconstruction 0lates for internalH;ation of 4ailchest in-uries. 6nn Thorac Surg

778?&9!(8 2ith 0ermission.Co ri ht 77 The Societ of


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;am0le of a/sor/a/le reconstruction0late secured 2ith a/sor/a/le suturecerclage. "1rom May/erry J, Terhes J,llis T, et al. 6/sor/a/le 0lates for ri/fracture re0air9 0reliminarye;0erience. J Trauma #$$(8&&9(?8

2ith 0ermission.%


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1lail chest is an uncommonconse)uence of /lunt trauma

:solated 4ail chest may /e successfully

managed 2ith aggressie 0ulmonarytoilet including facemask o;ygen, CP6P,and chest 0hysiothera0y

6de)uate analgesia is of 0aramount

im0ortance in 4ail chest 0atient arly intu/ation and mechanicalentilation is 0aramount in 0atients2ith refractory res0iratory failure orother serious traumatic in-uries


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Surgical sta/ili@ation is associated2ith a faster entilator 2ean, shorter

:C* time, less hos0ital cost, andrecoery of 0ulmonary function in a

select grou0 of 0atients 2ith 4ailchest


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The Management of Flail Chest - Tata

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