# Flail Chest Management



## medic89 (Jul 30, 2009)

I was looking through the PHTLS Version 6 book for the class I have tomorrow, and it states "Efforts to stabilize the flail segment by sandbags or other means is contraindicated."  Now, according to everything that I have read and remember from class, we are taught to stabilize the segment with an IV bag, or in BLS cases, a large stack of 4x4's and tape.  Is this a new thing that I haven't heard about, or am I just being stupid ?


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## 8jimi8 (Jul 30, 2009)

based on my basic class, they said, stabilize it with gauze or 4x4s.  I can't tell you about itls.   I'll tell ya next month after i take it


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## AZFF/EMT (Jul 30, 2009)

In my experience the only real way to stabilize a flail chest is through PPV with BVM. It's the negative pressure that causes the pain and movement of the flail segment so by using positive pressure you avoid that issue.


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## ResTech (Jul 30, 2009)

I dont see how 4x4's are going to help in stabilizing the flail segment. It is recommended to use a bulky dressing taped in place which will serve its purpose better. 

The whole purpose of "stabilizing" a flail segment is to try to maintain normal pressure volumes in the chest as to maintain normal breathing mechanics which will allow the patient to continue to breathe with normal or near normal tidal volumes. As AZFF/EMT said.... positive pressure ventilation with a BVM is the optimal way to stabilize a flail segment. The positive pressure pushes the flail segment outward and allows it to move in its normal manner. Do not use a BVM however, solely for flail chest segment unless the patient has indications for ventilatory support. Patients with flail chest hurt very bad when they breathe and will breathe very fast and shallow (decreased tidal volume) to try to limit the pain. This will reduce the minute ventilation which can prove to be detrimental in perfusion... so in this case you want to perform overdrive ventilation to make sure the patient is getting an appropriate tidal volume. 

Analgesics are also useful in the flail chest scenerio and can improve ventilatory status.... to decrease chest pain enables the patient to breathe deeper and more effectively.  

Placing a bulk dressing also serves to offer protection from bumps to the extremely painful fractured area.


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## medic89 (Jul 30, 2009)

Thanks everyone, the main reason that I was asking is that the ITLS book, my Paramedic book(Nancy Caroline's Emergency Care in the Streets), and a friends Intermediate book(all published by Brady, by the way) all say to stabilize the flail segment if paradoxical motion is noted.  PHTLS(published by Mosby) is the only reference that I have ever seen that states otherwise.


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## 8jimi8 (Jul 30, 2009)

ResTech said:


> I dont see how 4x4's are going to help in stabilizing the flail segment. It is recommended to use a bulky dressing taped in place which will serve its purpose better.




Sorry I wasn't explicitly clear.  a STACK of 4x4's i.e. a bulky dressing.  i'm not talking about taping 1 or two 4x4's and expecting that to stabilize a bunch of broken ribs...


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## ResTech (Jul 30, 2009)

A flail segment is somewhat of a large area to cover... that would take quite a few 4x4's in multiple stacks... a trauma dressing or two would work better.. just fyi.. 

I have only seen one flail chest in 15 years... was from a guy involved in an MVC who struck a utility pole.


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## mycrofft (Jul 31, 2009)

*AND how often would a flail chest also involve pneuomo or haemothorax?*

I've seen, maybe, one. Used to be much more common before shock absorbing steering columns. Used to see steering shafts through the chest, I've read.


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## 8jimi8 (Jul 31, 2009)

We carry massive stacks of unsterile gauze.  Not by regulation, but because people are too lazy to count to 30, so they just grab a handful and jam them into the bin.  Last time I actually counted the 4x4s we had 125.  Not too hard to grab a handfull of those and tape them down quickly.  I totally understand where you guys are coming from.  I would rather use up a bunch of unsterile gauze and save the ABD or Trauma Dressing for something that needs to be clean.  From the youtube video that i have seen of a flail chest, it seemed like my solution would cover the area well enough to support it.  I've never seen a flail chest on one of my patients.  Again, I totally hear what you guys are saying and really didn't mean to drag this out into a glorified rationalization...

so i'll stop beating the poor horse.  cheers!


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## sdadam (Aug 1, 2009)

I'm telling you guys, a "bulky dressing" isn't going to do anything at all but cover up the flail segment. 

You need a persons hand on there applying just enough pressure to keep the flail segment inline with the rest of the chest wall. I know what the book says, and frankly, it's wrong. it's like trying to control arterial bleeding with a "pressure dressing" you need one or two 4x4's at the tips of your fingers, dug down in the wound on-top of the artery. Not 20 4x4 with wrapped around it, that just gives the blood something to soak in to! 

Same idea with this, the whole bulky dressing thing will never put enough pressure in the right spot to really keep things together, it's too soft. You need the dexterity of a hand in order to both control the segment, and let the rescuer feel just what he is doing and adjust accordingly. 

I'm not making this up, although I have only seen this once, and it was in the hospital, so I didn't provide care, I just had a conversation with a trauma surgeon and all that was the advice she gave me.

I do agree that BVM is helpful too, but it should be done with someone stabilizing the segment, and again only if the PT needs to be bagged due to respiratory failure, not just because they have a flail segment.


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## Ridryder911 (Aug 1, 2009)

I never understood the "bulky dressing " philosophy either and when pinning anyone down on how to apply this, no one has an answer. The old method of a sand bag or IV bag to taping across make better sense but I can understand the reasons for removal as well. 

As mentioned the best way is to prevent the segment to move with positive pressure however; one has to be careful if there is underlying lung damage (i.e. pnuemothorax) as this may potentiate and increase the size to a tension pneumo. 

R/r 911


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## motomedic (Aug 2, 2009)

ResTech pretty much nailed it. enough said!


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## kecpercussion (Aug 2, 2009)

The "old school" management techniques, such as IV bags, are way more effective...i agree!


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## usafmedic45 (Aug 2, 2009)

> I do agree that BVM is helpful too, but it should be done with someone stabilizing the segment, and again only if the PT needs to be bagged due to respiratory failure, not just because they have a flail segment.



Agreed, that flail segment is not an independent indication for ventilation but I do have a comment regarding your other assertion.  Actually in a lot of cases, the positive pressure ventilation will stabilize it in and of itself (at least long enough for more definitive fixes to be undertaken).  Putting external pressure on the segment only increases the risk of pleural tears (greater risk of pneumothorax), increased hemorrhage and pulmonary compression which leads to increased airway pressures (since the lung can't expand as effectively under PPV) which adds another issue (barotrauma) to the list of risk factors for development of pneumothoraces.  That is the main reason the suggestion of laying an IV bag on the segment has been removed as a mainstream practice.  



> You need a persons hand on there applying just enough pressure to keep the flail segment inline with the rest of the chest wall.



The problem with that is what happens when you hit a bump in the ambulance and that "just enough pressure" becomes the equivalent of a really hard and poorly placed chest compression?


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## sdadam (Aug 4, 2009)

I don't see that as much of a concern to be honest, the person shouldn't be laying into the patient with all their weight.

The hand should be placed over the flail segment by a rescuer, with elbow bent, and gentle pressure applied. It's just the ability of a person to regulate pressure, and allow their arm to freely move that makes them an effective tool for this. 

A slightly bent arm, and a tentative EMT will be able to act as a shock absorber without much problem, and without the concern of performing an accidental chest compression.

As far as the other concerns, I believe the independent and untreated movement of free bone fragments causes the greatest concern of further lung, vascular, and nerve damage, rather than the act of stabilizing it physically. 

I'm no trauma Dr. though. I work with the same Dr. who taught me about these types of injuries tonight, I'll ask her thoughts on all this and let you guys know in the morning.


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## usafmedic45 (Aug 4, 2009)

> I don't see that as much of a concern to be honest, the person shouldn't be laying into the patient with all their weight.



Right, and I agree with that, however I have seen it with my own eyes when even the most attentive EMT gets suprised by a bump in the road or an abrupt stop and suddenly you wind up with several hundred pounds of force inadvertently applied to the wound. 

The thing is that if you really need to have the chest stabilized- and I'm talking the patient is actually unstable because of it- most likely that patient is going to buy themselves a tube because of respiratory failure (if not as a result of concommitant serious trauma) which effectively negates the need to stabilize the chest.  Otherwise, a folded and _tightly_ taped down trauma dressing or 5"x9" is going to more or less be sufficient to keep the flail segment in place since in cases without frank compromise of pulmonary fuction (small flail segments) it basically becomes an issue for pain control as much as for keeping the patient from deteriorating and decompensating during the ride to the hospital.  As someone who has had chest injuries before, let me tell you that if you have multiple broken ribs, the last thing you want unless you really need it is someone pushing on your chest even if they are doing it lightly.


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## 8jimi8 (Aug 4, 2009)

we covered this in my i-85 class.  Instructor said, " According to new research, we do not reinforce the flail segment.  We use internal splinting with a BVM."  My teacher did not distinguish that a person must require ventilatory assistance, as was implied earlier in the thread.  I found an entry in my book that said sling and swathe.


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## Ridryder911 (Aug 4, 2009)

8jimi8 said:


> we covered this in my i-85 class.  Instructor said, " According to new research, we do not reinforce the flail segment.  We use internal splinting with a BVM."  My teacher did not distinguish that a person must require ventilatory assistance, as was implied earlier in the thread.  I found an entry in my book that said sling and swathe.



Although, I do not disagree with their answer; I do ask where their sources and when tested I would be careful answering anything except in the NHTSA curriculum. 

R/r 911


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## 8jimi8 (Aug 4, 2009)

Thanks, I'll keep that in mind.  It reminds me of nursing classes.  We would have an option on a test that would try to make you decide between administering O2 and calling the doctor.  Well obviously in the real world you put the o2 on and then call the doc.  But for the test... you better pick call the doc because O2 is a "drug" and requires a prescription.  I think that is one of the things I love about EMS, running on protocols you don't need to wait for an order for something simple and straight forward.


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## Canoeman (Aug 5, 2009)

Flail - Learned this from an old collegue Bob Elling (Brady)-- Flail segment just stabilize with 3 inch Big *** tape holds the flail segment --- then ventilate as needed.


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## Akulahawk (Aug 17, 2009)

It's been a few years since I've worked as a Paramedic... but...

Flail segment? PPV will bring relief, but CPAP/BiPAP will also work. PPV with a BVM will be pretty tricky to do as you'll have to provide the inspiratory effort for the patient and allow the patient to exhale passivley and try to catch the end expiratory point so that there's never going to be a negative pressure gradient (below ambient). This would (in theory) keep the flail segment floating outside the chest wall area and not recontact the bone ends. 

Personally, unless the patient becomes or starts trending towards instability, I won't begin ventilation. Once that happens, ALL my attention will be put towards that and I'll essentially be useless for any other interventions that might be needed. If I can get an order for analgesics, that will reduce pain and keep the patient breathing more normally as they won't be breathing fast & shallow to limit pain...


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## RECON (Aug 21, 2009)

I had a motorcycle accident and hit the pavement at high speed and really hard.  It was Sunday afternoon.  I had displaced fractures of all my ribs front and back on my right side and 3 broken ribs on my left side.  The broken ribs perforated my right lung and almost completely severed my liver and spleen.  I was and still do take Plavix, warfarin and an aspirin daily.

I got up almost immediately after the accident.  I had on all the appropriate gear to include full leathers.  I didn't have a scratch on me.  I could not use my right arm so I couldn't lift up my bike.  I was trying to decide what to do, I was in an isolated area and in a lot of pain.  I have taken some really big hits in my life but this was right there in the top 2 or 3.  I finally realized I was bleeding, internally.  Once previously I had almost bled out and knew the symptoms.  I called 911.  They were there within minutes.

They put a cervical collar on me and asked me to lie down on a board.  I tried to explain that the pain was almost all in my shoulder and chest.  I told them I was bleeding, internally.  They checked me out and assured me I wasn't.  

As we were driving to the hospital I finally convinced the tech that I was bleeding by describing my symptoms and what was happening to my vision.  He took my blood pressure and became a believer.  They significantly increased their speed.  They were in contact with the UC Davis Trauma Center which is a level 1 Trauma center.  He started giving me oxygen.  He didn't take off my leather jacket, which he had unzipped or my shirt and so didn't know about the flail chest.

I had 3 operations the first week.  The problem was the Plavix which kept causing the repairs and reattachments of my liver to fall apart.

About the 7th day I was being lectured by the surgeon on the necessity to cough 100 times a day and the ICU nurses were counting.  Any movement by me at all, any, was excruciating pain.  

The next day the EMT tech stopped by to see how I was doing.  I said, "pretty good I think but the coughing is killing me."  He said, "use one of your pillows to hold against your right chest any time you move or cough and it will reduce the pain."  He was right and that was probably the very best thing that someone did for me, besides of course all the nurses and doctors saving my life.  It seems small but in fact it was a big deal and using the pillow to pull it into my chest seemed counterintuitive but it was exactly what I needed.


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