Chapter 21. Flail Chest. Mosby items and derived items 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
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1 Chapter 21 Flail Chest 1
2 Figure Flail chest. Double fractures of three or more adjacent ribs produce instability of the chest wall and paradoxical motion of the thorax. Inset, Atelectasis, a common secondary anatomic alteration of the lungs. 2
3 Anatomic Alterations of the Lungs Double fracture of numerous adjacent ribs Rib instability Lung restriction Atelectasis Lung collapse (pneumothorax) Lung contusion Secondary pneumonia 3
4 Etiology Motor vehicle accident Falls Blast injury Direct compression by a heavy object Industrial accident 4
5 Overview of the Cardiopulmonary Clinical Manifestations Associated with Flail Chest The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Atelectasis Pneumonic consolidation 5
6 6
7 7
8 Clinical Data Obtained at the Patient s Bedside 8
9 The Physical Examination Vital Signs Increased respiratory rate (tachypnea) Tachypnea occurs because of the following: Stimulation of peripheral chemoreceptors (hypoxemia) Paradoxical movement of chest wall see Figure 21-2 and Figure
10 The Physical Examination (Cont d) Vital Signs (Cont d) Decreased lung compliance/increased ventilatory rate relationship Activation of the deflation receptors Activation of the irritant receptors Stimulation of the J receptors Pain/anxiety 10
11 Figure Lateral flail chest with accompanying pendelluft. 11
12 Figure Venous admixture in flail chest. 12
13 The Physical Examination Vital Signs (Cont d) Increased Heart rate (pulse) Blood pressure 13
14 The Physical Examination Cyanosis Chest Assessment Findings Diminished breath sounds on both the affected and the unaffected sides 14
15 Clinical Data Obtained from Laboratory Tests and Special Procedures 15
16 Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Lung Volume & Capacity Findings VT IRV ERV RV VC N or IC FRC TLC RV/TLC ratio N 16
17 Arterial Blood Gases (Mild to Moderate Flail Chest) Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) ph PaCO 2 HCO 3 PaO 2 (slightly) 17
18 PaO 2 and PaCO 2 trends during acute alveolar hyperventilation. 18
19 Arterial Blood Gases (Severe Flail Chest) Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis) ph PaCO 2 HCO 3 PaO 2 (Slightly) 19
20 PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure. 20
21 Oxygenation Indices Q S /Q T DO 2 VO 2 C(a-v)O 2 O 2 ER SvO 2 N (Severe) 21
22 Hemodynamic Indices Severe Flail Chest CVP RAP PA PCWP CO SV SVI CI RVSWI LVSWI PVR SVR 22
23 Radiologic Findings Chest radiograph Increased opacity Rib fractures Increased density on the affected side 23
24 Figure A, Chest X-ray film of a 20-year-old female with a severe right-sided flail chest. B, Close-up of the same X-ray film, demonstrating rib fractures (arrows). 24
25 Respiratory Care Treatment In mild cases: Protocols Medication for pain and routine bronchial hygiene Severe cases Volume-controlled ventilation with PEEP 5 to 10 days usually adequate for sufficient bone healing 25
26 Respiratory Care Treatment Protocols (Cont d) Oxygen Therapy Protocol Lung Expansion Therapy Protocol Mechanical Ventilation Protocol 26
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