Flail chest w/ nemothorax

[ResTech]

Here is a great video that shows a actual patient with a flail chest.
[YOUTUBE]http://www.youtube.com/watch?v=e0VNBDbr67U[/YOUTUBE]

Just to add to the previous replies... on a BLS level (and even ALS level) there isn't a whole lot you can do specific to treating the actual flail segment. Your treatment is focused on the result of that flail segment which is ensuring an airway and maintaining adequacy of breathing.

Flail segments can result in an alteration of the normal mechanics of breathing (ie disrupts the pressure balance inside the chest) which can decrease gas exchange by not "drawing in" a normal tidal volume by a decreased expansion of the chest. So by stabilizing the flail segment you achieve two goals: 1) Protect the flail and vulnerable segment from additional injury during pt. movement and extrication. 2) Limit the movement of the flail segment to aid in chest expansion and reduce pts. pain. Don't look for significant result of splinting the chest but it is sometimes helpful. The pt. may also choose to self splint as well with their hand/arm.

The significant force it took to cause the flail chest is going to be causing the pt. a LOT of pain. So look for the pt. to be hypoventilating to try to reduce the chest movement as much as possible. For ALS, this is where analgesics can improve ventilation... by reducing the pain... pt. is able to breathe deeper... which equals greater tidal volume and improved ventilation. It may also be necessary to provide overdrive ventilation.

A flail segment is definitely a serious injury.... but more importantly it is the underlying pulmonary injury that warrants greater concern and will be causing the pt's. greater deal of respiratory compromise. If the force was great enough to cause a flail segment... imagine what the transfer of the blunt force did to the lungs and potentially the heart.... pulmonary/myocardial contusion, hemithorax, and pneumothorax are most common.

So tx wise.... BLS... high-flow O2, assist ventilations (BVM) PRN, splint/support flail segment.... and realize the possibility of a pneumo that may progress to a tension.... arrange for ALS... and appropriate trauma facility.

Hope this helps....

 

[Veneficus]

last reply to this foolishness

I have been in EMS long enough to know the deficiencies that exist in it. If you haven't noticed I am not the only one on this forum that notices it. Those that want to just stick their head in the sand and acknowledge their EMS system is perfect may be part of the problem. .

That is an interesting spin, but after reading your often degrading comments to and about EMS providers, residents, and junior physicians, I think you just harbor some kind of resentment. It must be hard to watch new people who will advance themselves beyond you, but you chose your path. You are not the only one wo has worked hard.

We have providers of many levels and different ages or experiences on this forum. I try to make statements of caution and post links for them to do more reading on their own. One shouldn't make their title of future doctor sound as a voice of authority and this is how it should be done..

I have decided my contribution was to share some of the techncal medical knowledge I have aquired. I would like to think it is not my title or perspective title that gives credibility to my posts but the knowledge and thought behind them.

Any provider is more than capable of measuring the merits of my opinions. I will not accept they are mindless sheep.

It is not me that constantly reminds EMS providers how undereducated and incapable they are, it is you.

I never said any one system was perfect. I was replying to your rather obvious insult to Florida.
Here is the quote by you again.

I have ignored many insults from you on my knowledge, capability, and contributions, it will not happen again.

Your zeal for improvement has turned into elite fanaticism over the last few months.

Do you know anything about the Ryder Trauma Center? Orlando Regional? Tampa General?

I can honestly say in my international travels I have never heard of them nor provider from them, perhaps I don't get out enough or spend enough time with trauma, but as it has been the focus of my professional persuits for almost 10 years, I don't think that is the case.

How about other states?
San Francisco General? R. Adams Cowley Shock Trauma Center?

Yes, I have heard of them, been to Shock Trauma, as well as centers all over the US and Europe, I admit I have yet to make it to Asia and look forward to a rotation in Israel and South Africa, where I have met great providers from, I didn't make the list of recognized trauma centers, but I know who is on it.

You have a very opinionated view of how things are done in a trauma center based on the one you have worked at.

You like to suggest how limited my travels and views are, as somebody who has traveled often at my own expense seeking out how things are done in other places in order to seek out those with outstanding practice and contribution, I find your remarks on such completely without merit.

Also, just seeing a trauma center is not always the same as actually working in one. Some things do change as different patients come in and different attendings are managing the rotations. The next day may be very different...

Yes, individual shifts can be different, but in my visits, some lasting as long as 14 days, I have been treated exceptionally well by great physicians who I admire and have a considerable higher opinion of my knowledge, experience, and dedication than you do. I just do't understand how senior surgeons seem to treat me better than an ancillary provider. But like many non physicians, they often like to sling mud to make up for their own inadequecies.

That is the beauty of medicine. There are many ways to accomplish similar goals..

again, backpeddling. Everytime I have made such a suggestion you have nit picked some detail, questioned my experience and knowledge, and suggested i am corrupting the youth that you call under educated and incapable of making a decision.

You have made alot of blanket statements. Yet even in the hospitals there will be protocols that may need to be followed even as a doctor.

Yes I have, and yes I know there are protocols, I am quite familiar with mine. But in order to have a discussion there has to be a starting point. You can nit pick because people like me make a blanket statement that can be clarified based on specific circumstances. But your what if or once upon a time critisism is old.

Don't expect an EMT(P) to challenge or disobey the written protocols of their medical directors just because you say so or try to call them incompetent for doing what is required of them..

First of all, I have warned against doing such, critisized those who suggested doing such, and suggested the proper professional way to suggest changes to protocol. I encourage all providers to think. I realize they have to follow the orders of their superiors, but again, I believe they have the ability to recognize that my opinion doesn't supercede their medical directors authority. For a self proclaimed academian you have a very narrow view of things you don't agree with and seem to frown on challenging practices while touting evidence based medicine. I have always been told questioning is a fundamental part of basic science. Einstein decided one day Newton's laws of physics were incomplete, it has changed the world.

seems kind of silly to hear you profess to want to advance EMS with "you're not capable do as your told."

However, there too they should not be bullied into going against their own judgement because you believe something is backwards by your own standards. You are not a doctor but you have made your opinions sound like you already are because you are a "med student"..

Your words not mine, I present what I think, which is perfectly within my providence, The only reason I elude t being a med student in my profile is because I am tired of being told I don't have enough knowledge as just a paramedic. I have no doubt people think that my opinions have merit, I'd like to think they are sound based on my education thus far. I am not a doctor, an vehemently dissuade people from referring to me as such. (ask around) I do that becuase unlike you I understand and have the highest respect the rigors of medical school and the lifestyle sacrifices associated. I do not try to substitute other courses for world accepted medical curriculum. There is no country on the map that doesn't recognize a doctor. How many can say the same of paramedics or RRTs? Infact as far as I know, more recognize prehospital providers than RRTs. That makes it a very niche market I think.

who does not have the full or any responsibility of a patient. That makes the licensed providers responsible for that patient and you when you are at that bedside.

extremely true and accurate, but the difference is I am encouraged to think and question by those providers because they are grooming me so that in some distantfuture I will the one responsible. You will never be, so maybe you should hold off on the statements of how little others know or experience.

You still have a long way to go in med school once you do get accepted..

It seems interminable.

You may not even achieve your goals at all for whatever reasons..

If I can breath, I will succeed. No matter where I have to go, or what I have to do. The goal is set, I will offer no excuses about family, difficulty, distance from home, or any other nonsense of I couldn't make it because...

I can guarantee your low opinions of other healthcare providers in EMS.

Funny, I was thinking the same thing about you.

nursing and the allied health professions will not be to your benefit.

Actually I do have a high regard and respect for members of those professions, but I have a great deal of contempt for specific indviduals in those professions who forget that the journey to "doctor" is considerably longer and harder or try to somehow "shortcut" the process with alternative curriculums and then have a lack of respect for those who actually go to medical school and subsequently residency or direct to practice depending on the nation.

 

[VentMedic]

Originally Posted by VentMedic
Do you know anything about the Ryder Trauma Center? Orlando Regional? Tampa General?

I can honestly say in my international travels I have never heard of them nor provider from them, perhaps I don't get out enough or spend enough time with trauma, but as it has been the focus of my professional persuits for almost 10 years, I don't think that is the case.

You insult the trauma centers of Florida but yet you have not heard of any of the centers in Florida that I have mentioned.

Yes, I have heard of them, been to Shock Trauma, as well as centers all over the US and Europe,

And you contradict yourself.

seems kind of silly to hear you profess to want to advance EMS with "you're not capable do as your told."

You don't advance until you have the education, backing of the profession and your medical director. There is no magic pill to take that gives one or a profession credibility over night.

But like many non physicians, they often like to sling mud to make up for their own inadequecies.

The only reason I elude t being a med student in my profile is because I am tired of being told I don't have enough knowledge as just a paramedic.

There is no country on the map that doesn't recognize a doctor. How many can say the same of paramedics or RRTs? Infact as far as I know, more recognize prehospital providers than RRTs. That makes it a very niche market I think.

Actually I do have a high regard and respect for members of those professions,

You really seem to be bothered by the thought of being just a Paramedic or some other lower level provider in the healthcare hierarchy. Not everyone wants to be a doctor and yet they can still provide care to a patient.

Your attitude and dislike for RRTs and RNs have now been evident in several posts. Were you denied entry into one of their programs of study?

Your contradictions and insecurities are too obvious. Maybe once you do finally get into medical school, you can feel more secure but you may also find out that med students often complain they don't get any respect until they are near the end of their residency.

It must be hard to watch new people who will advance themselves beyond you, but you chose your path.

I don't believe you have advanced passed me in either education or experience. That would definitely include my years of experience as just a paramedic.

At least I am consistent on my stance to being pro education for EMS. You have varied your stance on many topics on the different forums. As well, I will usually provide links for addition reading to allow others to form their own opinions. I link to resources so that others can learn from other information and not just from someone on an anonymous forum. I don't ask people to take my word for anything because I may not always have the right answer. Thus, the links to other sources are included in many of my posts.

 

[Veneficus]

do you actually believe this crap or do you just like to fight?

You insult the trauma centers of Florida but yet you have not heard of any of the centers in Florida that I have mentioned.
And you contradict yourself.

I have heard and been to shock trauma, I have heard of SF General, I have not heard of any in Florida, I can only conclude because they have not done anything to draw attention outside of Florida that has made it to main stream. It is not my fault that Florida trauma centers, which you seem to think are somehow superior to others, are not as well known as others. If you are insulted by that, maybe you should become a marketing director?

Is it really a contradiction to hear of famous trauma centers but not less well known ones?

I think you will need a better argument or should i believe that you couldn't figure out I had heard of some but not all of the ones you posted. Amazing I have heard of Groote Shuur hospital in South Africa, and Sourasky in Israel, but nothing from Florida. What can I say? "Sorry your facility didn't make the list." haven't heard of any in Montana, Alabama, Alaska, Maine, and I am sure a few other places either.

You don't advance until you have the education, backing of the profession and your medical director. There is no magic pill to take that gives one or a profession credibility over night. .

How dose debasing EMS providers help with any of that? Trying to goad them to action?

(Can't remember if it was Jefferson or Franklin that mentioned if you really want to stir somebody to action, insult them.)

You really seem to be bothered by the thought of being just a Paramedic or some other lower level provider in the healthcare hierarchy.

I do hate defending being a "paramedic." I have worked hard, perhaps more than some and less than others. Some may do the minimum I am not of that crowd and do not like being identified as part of it.

Not everyone wants to be a doctor and yet they can still provide care to a patient.

So what? There is a difference between providing patient care and second guessing physicians while possessing lesser medical education. I think some people do not see the difference between being a healthcare provider and a medical provider. (more people than you, have to use small words so I am not accused of contradicting myself)

Your attitude and dislike for RRTs and RNs have now been evident in several posts. Were you denied entry into one of their programs of study? .

I wouldn't say that, but I have to say after reading some of your posts, I would be embaressed to be associated with RRTs. You stand out among your peers I guess.

I have never applied to any program I was not accepted to. I am a proponent of economy of force and winning before I fight, not fighting to win.

RNs are their own breed, some great, some not so good, but I have seen a lot of them trash talk other providers. Seems kinda hypocritical for them to talk about other providers and not like thier flaws being pointed out? sort of like the pot calling the kettle black.

Your contradictions and insecurities are too obvious.

Really? I'd love to hear them. I think you are finding things that aren't there. Maybe you should see a doctor about that? (or a medicine man if that is your thing)

Maybe once you do finally get into medical school, you can feel more secure but you may also find out that med students often complain they don't get any respect until they are near the end of their residency..

LOL, that is awesome. "When I do finally get into med school." I must admit, I don't really know what to say to that. As for respect, from both my peers and superiors, I do quite well.

I don't believe you have advanced passed me in either education or experience. That would definitely include my years of experience as just a paramedic. ..

I don't really hold much stock in your beliefs. I wasn't speaking of you having to watch me advance past you, but I have seen your comments on junior residents. I would think they are well on their way to exceeding you, most probably have already, it doesn't seem like much of a task.

I believe you are educated far beyond your intelligence, but I doubt it matters to you, so I guess we play on a level field.

At least I am consistent on my stance to being pro education for EMS. You have varied your stance on many topics on the different forums.

Yes, my views have moderated over time, and as conflicting with EMS providers and agences doesn't seem to work, I am working on inclusion. Call it a softer sell. But I guess that might label me a flip flopper not fit for a republican ticket.

As well, I will usually provide links for addition reading to allow others to form their own opinions. I link to resources so that others can learn from other information and not just from someone on an anonymous forum. I don't ask people to take my word for anything because I may not always have the right answer. Thus, the links to other sources are included in many of my posts.

I get a lot of information from these things called a "textbooks," strange concept I know, but I figured somebody with your education in healthcare might recognize basic science when you see it or figure out how to google any information you think is invalid. Nobody is obligated to consider my opinion valid. I am a semi anonymous internet source. But anonymity does not automatically preclude knowledge. I am not a slave to money or fame.

"pay no attention to the man behind the curtain"
---The wizard (L. Veneficus) of Oz.

 

[VentMedic]

I have heard and been to shock trauma, I have heard of SF General, I have not heard of any in Florida, I can only conclude because they have not done anything to draw attention outside of Florida that has made it to main stream. It is not my fault that Florida trauma centers, which you seem to think are somehow superior to others, are not as well known as others. If you are insulted by that, maybe you should become a marketing director?

Is it really a contradiction to hear of famous trauma centers but not less well known ones?

So I ask you again, if you know nothing about Florida or its trauma centers, why did you feel it necessary to make the comments about them?

I could pick a lot of names off the internet to brag about also. However, I prefeer to use disclaimers when I do not know much about an area. I am not that familiar with north Florida so I usually allow Reaper to discuss that area. Sasha knows Orlando better than me and I respect that. Blsboy know the East Central coast better and FL_Medic knows the west central coast.

Nobody is obligated to consider my opinion valid.

You have wasted a lot of time trying to discredit "just paramedics", RNs, RRTs and other professionals just to prove your point which I don't even know what it was. You started rattling off stuff about yourself and clearly distracted from the subject of this thread.

And what is with the medicine man statement? Have you ran out of insults for "just paramedics" and other health care professions that you now must insult other cultures also?

As I stated in the earlier posts in this thread, you take things very personally. You can not stand the fact that "just a Paramedic" or an RRT would guestion one of your posts. Actually I believe this debate started with a question from an EMT-B which really must have offended your high standards for the professionals level which don't include anyone but doctors.

ResTech posted a great response to the OP. Take your personal issues to another thread of its own under personal musings or something and let the OP have his thread back.

 

[LAS46]

Wrong Place to Argue

I think the best place to take arguements as such is to private message... this is not to the place to do this in my opinion.

 

[VentMedic]

I think the best place to take arguements as such is to private message... this is not to the place to do this in my opinion.

You do know that it was one of your posts that initiated this discussion which turned into a hysterical display of egos?

 

[nomofica]

aaaaaaaaaaand cue lock thread.

 

[MSDeltaFlt]

Okie dokie. Back on topic before admin locks this bad boy.

On the BLS level. Treatment for a flail segment and pneumothorax is definitely splinting as others have already said.

As far as the rabbit chasing goes as far as to board or not, assess your pt. If you need to board them, then board them. If they are unable to tolerate lying flat on a LSB, who says they have to lie on a LSB for C-Spine Precautions? Spinal restrictions are for the spine. It does not mention the whole entire body. Short spine boards or KED's will work fine. Put them on one of these and elevate the head. Yes, it does work.

I'm living proof you can lay in bed in Semi-Fowler's with an unstable Hangman's Fx for over a week off of a board and not yet on a halo and still be cleared to go back to work without restrictions in less than a year. Let's look at the big picture, people.

As far as this heated debate goes, I'm going to let Admin address this.

 

[parapaulieFL]

yeah

Well you guys are right about spinal immob for just the flail segment...not gonna do much. But obviously consider MOI. Position of comfort wouldn't be acceptable for someone thrown through the windshield