Treatment for flail chest

Epi-do

Epi-do

I see dead people
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Just a quick question for everyone (I am also going to do my own research to see what I can find out on my own).

What is currently being taught to EMTs regarding the management of a flail chest?

I ask because we held a physical agility and practical testing today as part of the hiring process. For the trauma scenario the patient had a flail chest and an open tib/fib fracture. Of the nine canidates that we had, only three of them even acknowledged the fact that the patient had a flail chest. Of those three only one used a bulky dressing against the flail segment. A second put the bulky dressing on the opposite side of the chest as the flail segment, and the third person said they could use a bulky dressing but that BTLS is teaching to no longer do that. (Could anyone out there verify if this is true?)

We were just surprised that the other six didn't even acknowledge the injury and were trying to figure out why that may be. Thanks for any input you guys may have!
 
Epi-do said:
Just a quick question for everyone (I am also going to do my own research to see what I can find out on my own).

What is currently being taught to EMTs regarding the management of a flail chest?

I ask because we held a physical agility and practical testing today as part of the hiring process. For the trauma scenario the patient had a flail chest and an open tib/fib fracture. Of the nine canidates that we had, only three of them even acknowledged the fact that the patient had a flail chest. Of those three only one used a bulky dressing against the flail segment. A second put the bulky dressing on the opposite side of the chest as the flail segment, and the third person said they could use a bulky dressing but that BTLS is teaching to no longer do that. (Could anyone out there verify if this is true?)

We were just surprised that the other six didn't even acknowledge the injury and were trying to figure out why that may be. Thanks for any input you guys may have!
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buly dressing on the side of the injury. Why anyone would put a bulky dressing on the reverse side? I have no idea. I am told this doesn't really work anyway.
 
This is from PHTLS 6th Ed.

"Management of flail chest is directed toward pain relief, ventilatory support, and monitoring for deterioration. The respiratory rate may be the most important parameter to follow. Pulse oximetry, if available, is also useful to detect hypoxia. Oxygen should be administered and IV access obtained, except in cases of extremely short transport times. Support of ventilation with bag-valve-mask (BVM) assistance or endotracheal intubation and positive-pressure ventilation may be necessary (particularly with prolonged transport times). Efforts to stabilize the flail segment with sandbags or other means are contraindicated."

PHTLS, BTLS, ATLS; they're all sponsored by the American College of Surgeons.

The reason they don't want you to mechanically stabilize the flail segment is because of the pain. Two or more fractured ribs in two or more places creating a floating segment is going to hurt like hell. You're not likely to see it in the early phases due to spasms with the intercostal muscles causing a splint of the segment. You might be able to on palpation if they let you. Remember, it's going to hurt like hell.

If you see paradoxical movement, it's a late sign. By then, the pt will be hypoxic and so compromised, you'll need to bag them. THAT's the definitive treatment.
 
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Thanks alot Mike! I knew someone here would be able to help me out. I did also find a couple good articles that stated the same as the PHTLS book you quoted. I passed the information along to those involved in the hiring process (including our EMS chief, so hopefully there will be an upcoming training to update everyone to the latest information). In our scenario, there was crepitus and diminished breath sounds on the right. There was also supposed to be unequal rise and fall of the chest.

The reason for not mechanically stabilizing the chest makes total sense. All in all, it was a good scenario if for no other reason than it made me do some research and learn something new when the day was over.

Again, thanks for you help!
 
Fascinating! Anyone have any other information? What about pain control prior to manual stabilization, ie: sandbag or bandaging? Isn't the point to reduce movement of the affected chestwall valid?

Any other BTLS/PHTLS revisions that have come about in the last 3 or so years?
 
Flail Chest.

1. Have pt. take deep breath in, place bulky dressing in hole.
2. Have pt breathe out while you are holding bulky dressing, and at end of exhalation (sp?) tape in place.
 
CPG said:
Flail Chest.

1. Have pt. take deep breath in, place bulky dressing in hole.
2. Have pt breathe out while you are holding bulky dressing, and at end of exhalation (sp?) tape in place.
Click to expand...

This is from PHTLS 6th Ed.

"Management of flail chest is directed toward pain relief, ventilatory support, and monitoring for deterioration. The respiratory rate may be the most important parameter to follow. Pulse oximetry, if available, is also useful to detect hypoxia. Oxygen should be administered and IV access obtained, except in cases of extremely short transport times. Support of ventilation with bag-valve-mask (BVM) assistance or endotracheal intubation and positive-pressure ventilation may be necessary (particularly with prolonged transport times). Efforts to stabilize the flail segment with sandbags or other means are contraindicated."
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Efforts to stabilize the flail segment with sandbags or other means are contraindicated
 
Flail Chest:

Give BVM to patient. Tell him that forcing air into his lungs will move his chest out together with the flail section minimizing pain. Sucking air in will cause the flail section to move opposite his ribs causing extreme pain.

They will gladly bag themselves.
 
it does beg the question...

why, in the EMT curriculum, are we taught to stabilize with a bulky dressing, only to learn afterwards that this is contraindicated?

you can easily see the confusion...

most who have taken PHTLS will not stabilize, and most who have not taken PHTLS will stabilize...

must be an easier way!
 
well has anyone seen the most recent "B" curriculum? Does anyone have a book from the past year or so laying around?
 
EMS179 said:
well has anyone seen the most recent "B" curriculum? Does anyone have a book from the past year or so laying around?
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In class now. With respect to closed chest injuries, including flail chest, my book (EMT Complete) says:

"If the patient is responsive, identify the specific injury site by questioning the patient and by palpation. Attempt to splint the injury site by placing a large trauma dressing, folded towels, or a blanket firmly over the site. This will help splint the injury, thereby reducing the pain and allowing the patient to breathe more easily."

So, yes, it's still being taught in B classes to splint a flail chest.
 
Sapphyre said:
In class now. With respect to closed chest injuries, including flail chest, my book (EMT Complete) says:

"If the patient is responsive, identify the specific injury site by questioning the patient and by palpation. Attempt to splint the injury site by placing a large trauma dressing, folded towels, or a blanket firmly over the site. This will help splint the injury, thereby reducing the pain and allowing the patient to breathe more easily."

So, yes, it's still being taught in B classes to splint a flail chest.
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I was taught the same thing. I was very surprised to see this thread, since I got certified in August last year, and we were taught to place a bulky dressing over the segment and tape it from uninjured side to uninjured side.
 
seanm028 said:
I was taught the same thing. I was very surprised to see this thread, since I got certified in August last year, and we were taught to place a bulky dressing over the segment and tape it from uninjured side to uninjured side.
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yes.. that is the whole point...

everyone is taught to splint the flail segment in EMT class...

it is only after class, if you are in a medic class perhaps, or taking the PHTLS class that you come across information saying that splinting the flail segment is contra-indicated.

the issue i have, is this... according to our county, if there something not exactly specified in the protocols, such as splinting flail chest, the issue reverts back to curriculum used by NYS, which would be to splint...

it is a similar issue with the long board, as i have already gone down this path with the state... many services can use a full body vacuum splint in place of the LSB... i approached the county with this, as the protocol does not specify what device you can use... since the full body vacuum can become rigid, and has many benefits, i wanted to use them. as per the county, the NYS curriculum specifies the LSB, and no other devices, and that is all we are cleared to use. they acknowledged that change is in the works, and that clarification is needed, but it is not there now.

i wonder what the take would be on a state level regarding splinting vs. not splinting the flail segment...

perhaps, i will put in a call tomorrow...
 
skyemt said:
yes.. that is the whole point...

everyone is taught to splint the flail segment in EMT class...

it is only after class, if you are in a medic class perhaps, or taking the PHTLS class that you come across information saying that splinting the flail segment is contra-indicated.

the issue i have, is this... according to our county, if there something not exactly specified in the protocols, such as splinting flail chest, the issue reverts back to curriculum used by NYS, which would be to splint...

it is a similar issue with the long board, as i have already gone down this path with the state... many services can use a full body vacuum splint in place of the LSB... i approached the county with this, as the protocol does not specify what device you can use... since the full body vacuum can become rigid, and has many benefits, i wanted to use them. as per the county, the NYS curriculum specifies the LSB, and no other devices, and that is all we are cleared to use. they acknowledged that change is in the works, and that clarification is needed, but it is not there now.

i wonder what the take would be on a state level regarding splinting vs. not splinting the flail segment...

perhaps, i will put in a call tomorrow...
Click to expand...

Regardless of what PHTLS, BTLS, ATLS, or whatever cert you may have shows you even with emperical data, they will also tell you somewhere in the literature to follow your local protocols. It's a little "save your butt" disclaimer that every book's legal department makes them print before they sell the cotton-pickin' thing.
 
As an EMT, you should bandage the flail segment. This may be ancedoctal, but twice before I have seen it help with patient's pain myself. The current version of "Emergency Care" describes the use of a bulky bandage taped in place, 02, and careful monitoring for respiratory compromise.
 
Does anyone use/stock or learn how to use the Asherman chest seal? Essentially its a big sticker with a one-way-valve on it. We used them a lot in Israel, and i know they are manufactured here, but I havent seen one.
 
emt-student said:
Does anyone use/stock or learn how to use the Asherman chest seal? Essentially its a big sticker with a one-way-valve on it. We used them a lot in Israel, and i know they are manufactured here, but I havent seen one.
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I know of services in NY that have them, but have never seen them actively used. However, unless the flail chest has caused an open pneumothorax, I don't believe that that device would be of any use in this situation.
 
I apologise, it is a bulky dressing bandaged in place. Earlier I state a bulky "bandage" taped in place.
 
I am also in medic school, and we have the current PHTLS book which states to not stabilize a flail segmant. However, I just signed up for ITLS at work, and after reading, it states: Be sure flails are well stabilized.

This is the Brady book (ITLS) 6th edition. I believe it is the newest. Sooo... I'm late for my class, catch ya later!

-rye
 
I had a patient involved in an MVC with a pneumo and flail chest with paradoxical breathing upon initial assessment. We placed a trauma dressing over the flail segment and taped in place primarily just to provide protection to the flail segment. A bulky dressing helps reduce pain from inadvertent pressures or bumps to the flail segment during field care.
 
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