flail chest

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.


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.


However, a flail segment will also be pushed out while the rest of the rib cage contracts.


Two Types

Flail Chest – TypesFlail Chest – Types

Since the flail segment moves in an opposite direction to rest of the chest wall


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


Analgesia.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)


Intubation & 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.


Chest Tube Insertion

To treat hemothorax

To treat pneumothorax


Rib Fracture FixationUsually not requiredPreferred choice before intubation & ventilation.


PhysiotherapyTo aid better drainage of secretionsTo rebuild musculatureTo reposition chest wallCoughing exercisesResistance exercisesTrunk exercises


Rehabilitation12 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.

flail chest

Healthcare