Flail Chest Management

[Akulahawk]

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...

 

[RECON]

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.