Flail chest w/ nemothorax

[nomofica]

The "hug a pillow" method in conjunction with a couple of elastic roller bandages will stabilize without putting undue pressure on the rib cage (Vent, jump in here and hit me with a wet noodle if I'm off base). The thing you want to avoid is localized pressure on the underlying bone structure/organs. The pillow will diffuse the force and still support the thoracic structure.

Yeah, I've heard of EMS grabbing the pillows off of their cots and "taped" them on to the patient

 

[Flight-LP]

I dont know about your area, but here, you cannot pull up on scene and administer ANY medication without working under the medical directors license, and even then you have to wait for the ambulance to bring equipment, and definately not as a volunteer. Not only that, but we have to have tags/stickers on our vehicle that states what we are carrying on our automobiles...

Care to elaborate???

My former agency, the largest ESD in Harris County, had plenty of ALS first responders, some of which were volunteers. All were fully ALS equipped and most didnt have to wait for the unit to arrive. None have any sort of tag or sticker, never heard of that one. Is it a local thing for you?????

 

[nomofica]

I dont know about your area, but here, you cannot pull up on scene and administer ANY medication without working under the medical directors license, and even then you have to wait for the ambulance to bring equipment, and definately not as a volunteer. Not only that, but we have to have tags/stickers on our vehicle that states what we are carrying on our automobiles...

We have Good Samaritan laws that state you can do anything up to the extent of your medical knowledge ONLY if the patient consents (either expressed or implied from patient OR a family member in the case of a child or incompetent adult) . If a lay person knows CPR and a person needs it, the lay person administers. If a BLS EMT happens across an MVA that requires medical attention, the off-duty EMT is allowed to administer whatever he can with the available equipment until a rig arrives.

As soon as you start administering treatment, you CANNOT stop until:
A) a more qualified individual arrives on scene (exception to this is if they ask for your assistance for two-rescuer CPR or whatever they need) If they need your help, YOU HELP.
B )"injuries are obviously incompatible with life". If the patient's brain is eviscerated from the skull, etc, obviously he's (due to a lack of better words...) a "goner".
C) You are too exhausted to continue (as with CPR)

 

[EMTelite]

3 way flutter valve occlusive dressing high flow oxygen via non rebreather be prepared for BVM which more than likley will need to be used because of poor tidal volume, apply bulky dressing too the affected side secure in place witha roller bandage

 

[LAS46]

A spine board is not indicated, and not likely to immobilize the segments of the rib cage, which will move each time the patient breathes. Positioning the patient lateral recumbent on the affected side is the textbook preference. However in reality, the patient should be allowed to assume the position most comfortable to him or her.

Oxygen is obviously indicated, but other than that, there is no treatment, just supportive care.

I would place this PT on a spine board even though you say it is not indicated. If the PT was in a MVA then they should be in full c-spine precautions. You can adjust your straps to work around the injury. Spider straps would not be recommended, insted I would use nylon seat belt type straps. And like everyone else has said NRB 15lpm, treat for shock, Call for ALS to meet you enroute, and occlusive dressing if open.

Dustin
NREMT-B Student

 

[Sasha]

I would place this PT on a spine board even though you say it is not indicated. If the PT was in a MVA then they should be in full c-spine precautions. You can adjust your straps to work around the injury. Spider straps would not be recommended, insted I would use nylon seat belt type straps. And like everyone else has said NRB 15lpm, treat for shock, Call for ALS to meet you enroute, and occlusive dressing if open.

Dustin
NREMT-B Student

Ahhh we're going to get in to a discussion about spine boards and their useless now. Wasn't their popcorn floating around on another thread??

 

[Veneficus]

I would backboard this pt. because a trauma significant enough to cause flail chest is definitely significant enough to cause spinal trauma.

I must respectfully disagree, the thoracic cage requires considerably less force both directly or indirectly to fx than a spine.

also bear in mind when you board a patient, you restrict chest expansion, which will inhibit breathing, but the actual cause of death is the aortic occlusion.

At the basic level, call med control and tell them what you see and ask them what to do when you are already on the way to the hospital. If you have a significant transport time, they may consider walking you through a decompression.

splinting the flail is a great idea, it will help the breathing.

the bright side is an open pneumo you can treat and a closed one will last a fair amount of time before decompensation depending on the size of the pneumo. (estimated by breath sounds in the field)

If I wanted to be smart, I could say the treatment is going to paramedic school

 

[Veneficus]

I would place this PT on a spine board even though you say it is not indicated. If the PT was in a MVA then they should be in full c-spine precautions.

Why?








10characters

 

[LAS46]

Why?
10characters

Well hello!! Look at the MOI, anyone with a significant MOI under NREMT protocols says that they must be in FULL c-spine care.

MOI- MVA with PT thrown from vehicle.

Dustin
NREMT-B Student

 

[emtjack02]

At the risk of opening the boarding debate..are you questioning why they would board them? Or that this pt does not need to be boarded.

 

[LAS46]

At the risk of opening the boarding debate..are you questioning why they would board them? Or that this pt does not need to be boarded.

Like I said with the MOI that the PT has displayed with I would be inclined to follow NREMT protocol and have the PT is full c-spine care.

Dustin
NREMT-B Student

 

[Sasha]

Might i refer you to this thread from our abstract service that find the harm and uselessness in backboarding?

http://www.emtlife.com/showthread.php?t=12256

And even doing a search will find you many more threads that debate backboarding.

Blindly following protocols may do more harm then good to your patient. With the dyspnea and pain that follows a pnuemo, they're likely to squirm and try to get more comfortable. Have you been on a backboard for ANY amount of time? Healthy as a clam, it's very uncomfortable. I can imagine that laying supine on a stiff non anatomical board, strapped down with a hole in your lung feels much worse.

And what is someone's instinct when you're having trouble breathing? Sit up.

 

[Shishkabob]

Well hello!! Look at the MOI, anyone with a significant MOI under NREMT protocols says that they must be in FULL c-spine care.

MOI- MVA with PT thrown from vehicle.

Dustin
NREMT-B Student

First, NREMT doesn't have protocols.


Second, and I hope you teacher taught you this, what is taught in class and in the book should never be followed blindly and without thought.

Example-- "By the book", you do 30 compressions and then 2 breaths. Real world, you do compressions while doing breaths.

 

[LAS46]

First, NREMT doesn't have protocols.


Second, and I hope you teacher taught you this, what is taught in class and in the book should never be followed blindly and without thought.

Example-- "By the book", you do 30 compressions and then 2 breaths. Real world, you do compressions while doing breaths.

For this PT and the experience I have in the EMS field I would still back board this PT to keep from risking further injury. As you know as EMT-P with a flail chest wound if the PT moves around a lot they can cause them selves more injuries... so by using full c-spine precautions you will be doing more good for your PT than not. And even if there was no flail chest wound full c-spine care would be in order due to the MOI.

Dustin
NREMT-B Student
Graduating EMS School Tonight

 

[VentMedic]

Why?

The first 10 vertebrae are fixed with their articulation to the thoracic cage.​

For some mechanisms that cause flail chest, especially motorcycle accidents, can cause forced hyperflexion of the thoracic spine. The anatomically narrow thoracic spinal canal also leads to a high incidence of associated neurologic complications. The higher the rib fxs the more chance of also finding spinal injuries. The younger the child, the more chance of spinal injuries since it takes great force to break the flexible ribs of the very young. ​

These patients will almost always get a CT scan to rule out organ damage and spinal fractures. ​

While the back board is not always the best method of stabilizing the spine, consideration of spinal injuries should still be there. Also, neurologic deficits may not always be initially present. Once they become apparent, the patient's spinal injuries may have progressed from stable to unstable.​

 

[syd]

What is the proper way to splint a flail chest? I was told in my class that it was to splint it when it's "in"... is that right?

 

[emtjack02]

If the MOI supports boarding as do your protocols I think one should evaluate if the pt is going to tolerate it..if so board.

To address the example if you have an advanced airway then by all means you can vent/comp asynchronously.

 

[LAS46]

If the MOI supports boarding as do your protocols I think one should evaluate if the pt is going to tolerate it..if so board.

To address the example if you have an advanced airway then by all means you can vent/comp asynchronously.

I just spoke to our medical director for my area and he said ALL trauma PTs must be backboarded even if they present with a Flail Chest wound. He also said of course most PTs will not like being on a spine board but they need to be until xrays and CTs can be done to r/o and spine or further internal injuries.

Dustin
NREMT-B Student
Graduating EMS School Tonight

 

[Veneficus]

The first 10 vertebrae are fixed with their articulation to the thoracic cage.​

they are planar joints, which do freely move connected by dense connective tissue to limit that movement. Just as when you fall on an outstretched hand, you are more likely to rupture a joint capsule that produce a collies fx. I amnt saying it can't or doesn't happen, it is not as common.

For some mechanisms that cause flail chest, especially motorcycle accidents, can cause forced hyperflexion of the thoracic spine.​

since I was dealing with the MVA patient in this scenario, I was trying to acertain "what mechanism" was leading to the suggestion of a spinal injury for the purpose of determing if there was clinical reasoning or following a cookbook.

I still have this crazy idea that guidence works better than telling people how wrong or undereducated they are.

The american college of surgeons still considers gunshots to be the number 1 cause of spinal injury, whch may not damage the cage at all, but the scenario was not: "I think the patient was shot while driving."

I am not trying to suggest there are not times when the mechanism that fractures a cage also fractures the spine, the amount of rib fx without cord damage far outnumbers that with cord damage globally.

The anatomically narrow thoracic spinal canal also leads to a high incidence of associated neurologic complications. The higher the rib fxs the more chance of also finding spinal injuries. The younger the child, the more chance of spinal injuries since it takes great force to break the flexible ribs of the very young.

These patients will almost always get a CT scan to rule out organ damage and spinal fractures. ​

undoubtly, are you suggesting I don't know the course of the treatment after the pt reaches the hospital or how to care for different age groups? But look at the treatment of spinus or transverse process fractures and many other non subluxations. what weight is given to ischemic cord injury (by far the most common) rather than transection or penetration? There has to be a very serious injury for a spinal surgery to be attempted.


There is also the knowledge that those with c or t fractures also have fractures of the opposite which show up on imaging and are often missed during examination. The day there is a one size fits all trauma treatment, I am quiting.

We could also talk about osteomalacia and osteoporosis in the elderly too, but i am trying hard to work with what was given and not debate every possibility. c'mon.

While the back board is not always the best method of stabilizing the spine, consideration of spinal injuries should still be there.

and I agree with this fully, but there is a difference between realistic index of suspicion, especially when you consider the rareness of cord injuries in a modern automobile and mechanism by speed or damage shown not to be reliable.

Additionally without critical thinking, there can be no improvement of patient care.

 

[Veneficus]

sorry got confused

I accidentally mixed this reply with one on a different board, I guess i am fired.


but my opinion still stands.