# flail chest?



## daedralarsa (Dec 5, 2007)

okay i never quite understood what your supposed to do when someone an injury to the chest. ive heard the term paradoxical movement...but what is supposed to be done when you find this during assessment?


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## Meursault (Dec 5, 2007)

I'm surprised your text didn't cover this immediately after telling you the assessment signs. The textbook answer is a "big bulky bandage" to immobilize the floating section. If it's  of the full-scale floating sternum variety, I don't think there's much you can do aside from trying not to overtighten the chest straps.

Anyone have practical advice?


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## Arkymedic (Dec 5, 2007)

daedralarsa said:


> okay i never quite understood what your supposed to do when someone an injury to the chest. ive heard the term paradoxical movement...but what is supposed to be done when you find this during assessment?



Flail chest occurs when the thoracic wall breaks and detaches. It is mostly seen in MVCs, trauma from blunt objects, etc. This is very critical because it also has major problems for the pulmonary system. When someone inhales the chest wall typically moves outward due to negative pressure but with a flail segment the chest wall will move inward while the rest of the chest moves outward. During normal expiration the chest wall contracts inward releasing air upward but a flail segment will push outward while the rest of the chest moves inward. That is paradoxical movement and there will more than likely be crepitus as well. There is also a high chance of a pneumo if untreated quickly due to broken bone. 

Tx is dependent on local protocol but some generic are as follows:

Tx BLS level:
BSI
Assess airway
O2 @ 15 LPM via NRB but prepare for probable BVM use as well. By using the BVM you provide the pressure to stabilize lung expansion.
Look for sucking chest wound and seal with occlusive dressing on 3 sides or all 4 again depending on protocol. If a flail chest is found (remember to check the back as well) then stabilize with bulky dressing. If possible you can also place the patient injured side down. If there is an object impaled leave it stabilizing in place and initiate spinal immobilization and rapid but careful transport to trauma center or closest hosp depending on prot. Listen to LS and watch for pt improvement as a bulky dressing will help to stabilize breathing irregularity and improve respiratory function. 

If an ALS intercept or helicopter does not compromise pt stability I would consider it as well. ALS is probably going to intubate, start a line, CM, if it leads to pneumo decompress, treat for hypotension, and in some states provide pain management. 

Surgical intervention is more than likely going to be needed.

Again true tx is going to be based on your individual protocol


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## daedralarsa (Dec 5, 2007)

ive heard of applying a big bulky dressing, or something about stabilizing the area with the pt's arm.  
but how do you apply a bandage if there is possible spinal injury as well
and what exactly does the dressing do/help with?
sorry for the dumb questions


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## daedralarsa (Dec 5, 2007)

ah well you answered the majority of my questions
ill ask my instructor tomorrow to demonstrate what you've told me
thank you


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## Arkymedic (Dec 5, 2007)

daedralarsa said:


> ive heard of applying a big bulky dressing, or something about stabilizing the area with the pt's arm.
> but how do you apply a bandage if there is possible spinal injury as well
> and what exactly does the dressing do/help with?
> sorry for the dumb questions


 
I have always used a trauma dressing and secured with crevats (aka triangle bandages) An IV bag or sandbag can be used as well. Apply it to the side that flail segment is on to fix the pressure inside and stabilize the ribs to keep from leading to a pneumo. The bandage can also be taped in place. Check out this video for an example of paradoxical movement and for further general info. Again it is all pursuant to local and service protocol on how it is dealt with.


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## Ridryder911 (Dec 5, 2007)

This has always been a controversial subject. In the old days (yes, before my time) they used to actually place hooks in the chest wall, and attach them to ropes to pull the chest wall. I was taught to use heavy object to stabilize such as a sandbag, or IV bag, later only to find out that it was not effective either. Now, the current treatment as described by Arkymedic, is to use bulky dressing, and to self stabilize with the arm or swathe. 

Positive pressure ventilation is sometimes recommended, but with this comes dangers as well. Increasing the risks of barotrauma and introduction of small pneumos becoming bigger ones, increasing parenchymal trauma.

Like Arkymedic also describes that one should pay close attention of possibility of other underlying injuries or potential injuries. Sucking chest wounds, as well plural contusion, myocardial injuries. 

So what to do? BLS, is basically supportive treatment. Secure bulky dressings, if possible have the patient support the ribs (probably already performing this) and the main point is again to look and observe for other injuries. Chances are they have other injuries, it can be an isolated injury but rarely. Treat appropriately as described with oxygen and if needed ALS. Not all flail segments are pneumos, and not all need aggressive treatment, it is just a high indication of potential injuries. 

R/r 911


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## emtangie850 (Dec 9, 2007)

If you don't have a bulky trauma dressing available you could also use a pillow or sheet. What I would do if there is a possible neck/back injury is  secure the bulky dressing with triangular bandages. With extra hands you could achive this by tying a few bandages together, (depending on the patients size) slide it through a handle (while patient is being lifted on board) through the handle on the other side, and then tie it on the opposite side of the injury (on chest)- this way you can adjust the pressure.

There are more practical ways such as the board straps or spider straps, but if you are in an akward situation there is always something you can do to improvise! 

Anything to help the patient feel more comftorable will help.

I hope this helps!

-Angela


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## rhan101277 (Jul 20, 2009)

I found a good video on youtube showing a flail chest.

http://www.youtube.com/watch?v=OzBmQi5rgTE&NR=1


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## Double-E (Jul 20, 2009)

this is my fav ^_^

http://www.youtube.com/watch?v=e0VNBDbr67U

from what i understand the whole bulky dressing thing doesnt really work and will likely be phased out of treatment protocol eventually...


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## AnthonyM83 (Jul 20, 2009)

Some texts are now advising not to attempt stabilization of the flail segment.
Support with oxygen and possibly BVM, as their tidal volume might be decreased due to painful inspirations (which would be particularly worrisome in trauma patients).


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## MrBrown (Jul 20, 2009)

AnthonyM83 said:


> Some texts are now advising not to attempt stabilization of the flail segment.
> Support with oxygen and possibly BVM, as their tidal volume might be decreased due to painful inspirations (which would be particularly worrisome in trauma patients).



We classify a flail chest at three or more ribs broken in two or more places.

Prehospitally I'd focus on agressive pain management (I'd insist on an Advanced Paramedic to administer ketamine) and ventilatory assistance (oxygen via NRB at 8lpm or BVM at 10lpm) and rapid transport.

I do believe that a flail chest would (where they exist) meet our trauma bypass policies.


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## sdadam (Jul 20, 2009)

To treat a flail segment, someone should place their hand over it gently, preventing the segment from moving outward from the rest of the chest. There isn't much you can do from the outside in order to keep the segment from moving inward. This should be done by a rescuer, and maintained all the way to the hospital. I wouldn't recommend bulky dressings, or using the patients arm, as neither works well. 

You basically have to use up one rescuer just stabilizing the chest wall, but it's the best way to do it. Gently is key, people tend to push downward and further inhibit chest wall movement, which is bad, your hand isn't pushing it's just stabilizing the pieces as best as possible.

Hope that helps.


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## mycrofft (Jul 21, 2009)

*Presentations differ and interventions are affected by resouces and where you are.*

As with most violences to our bodies, flail chest rarely if ever presents as a clean discrete problem. What if some of the ribs are broken but not all of them in a chest segment? Or they tear loose at the sternum but remain mutually attached and still somewhat contiguous with the spine? What about haemo, pneumo, or haemo-pneumo thorax, intracranial and spinal insult from that amount of force? What's killing them first?

You will see mixed signs and symptoms and complaints, follow your protocols but if they aren't working go to another plan, or entertain the thought your most urgent problem has changed, and don't dither on scene. "Cutting to the chase", the patient needs a hospital. If they can't or won't get it, the likelihood is that they are going to die. 

PS: in the day, we used to have the pt lie on the affected side. Not a bad trick if you're faced with a overwhelming casualties and minimal resources, put in recovery position on the affected side, tag and flag, then continue your survey.


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## atb123 (Jul 23, 2009)

I work in a fairly large urban department. Our standards for a flail chest is monitor with hi flow O2 and BVM if it will help. The bulky dressing, IV bag, or sandbag is no longer recommended. The BVM is referred to as an internal splint and supposedly alleviates pain of inspiration and keeps sats up.


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## wyoskibum (Jul 23, 2009)

daedralarsa said:


> okay i never quite understood what your supposed to do when someone an injury to the chest. ive heard the term paradoxical movement...but what is supposed to be done when you find this during assessment?



My first ever flail patient would not lay supine on the backboard.  He insisted on laying on the injured side.  Turns out that was the best stabilization for the flail segment.  So we did the best spinal stabilization we could with the pt in a left lateral recumbant position.


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