copyright © 2006 by mosby, inc. slide 1 part v chest and pleural trauma

Copyright © 2006 by Mosby, Inc.Slide 1

Part VPart VChest and Pleural TraumaChest and Pleural Trauma


Chapter 21Chapter 21Flail ChestFlail Chest

Figure 21-1. 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.


Anatomic Alterations of the LungsAnatomic Alterations of the Lungs

Double fracture of numerous adjacent ribsDouble fracture of numerous adjacent ribs

Rib instabilityRib instability

Lung restrictionLung restriction

AtelectasisAtelectasis

Lung collapseLung collapse

Lung contusionLung contusion

Secondary pneumoniaSecondary pneumonia


EtiologyEtiology

Direct compression by a heavy objectDirect compression by a heavy object

Automobile accidentAutomobile accident

Industrial accidentIndustrial accident


Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated

with FLAIL CHESTwith FLAIL CHEST

The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by AtelectasisAtelectasis (see Figure 9-7) and (see Figure 9-7) and Pneumonic ConsolidationPneumonic Consolidation (see Figure 9-8)— (see Figure 9-8)—the major anatomic alterations of the lungs the major anatomic alterations of the lungs associated with flail chest (see Figure 21-1).associated with flail chest (see Figure 21-1).


Figure 9-7. Atelectasis clinical scenario.


Figure 9-8. Alveolar consolidation clinical scenario.


Clinical Data Obtained at theClinical Data Obtained at the Patient’s Bedside Patient’s Bedside

Vital signsVital signs

Increased respiratory rateIncreased respiratory rate Stimulation of peripheral chemoreceptors Stimulation of peripheral chemoreceptors

Other possible mechanismsOther possible mechanisms

• Decreased lung complianceDecreased lung compliance

• Activation of the deflation receptorsActivation of the deflation receptors

• Activation of the irritant receptorsActivation of the irritant receptors

• Stimulation of the J receptorsStimulation of the J receptors

• Pain/anxietyPain/anxiety

Increased heart rate, cardiac output, blood pressureIncreased heart rate, cardiac output, blood pressure


Figure 21-2. Lateral flail chest with accompanying pendelluft.


Figure 21-3. Venous admixture in flail chest.


Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside

Paradoxic movement of the chest wallParadoxic movement of the chest wall

CyanosisCyanosis

Chest assessment findingsChest assessment findings Diminished breath soundsDiminished breath sounds

• On the affected as well as the unaffected sideOn the affected as well as the unaffected side


Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special

ProceduresProcedures


Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings

VT RV FRC TLC

N or

VC IC ERV RV/TLC%

N

VT RV FRC TLC

N or

VC IC ERV RV/TLC%

N


Arterial Blood GasesArterial Blood Gases

Mild to Moderate Flail ChestMild to Moderate Flail Chest

Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)

pH PaCO2 HCO3- PaO2

(Slightly)


Time and Progression of Disease Time and Progression of Disease

100100

5050

3030

8080

00

PaCO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaO2

Disease OnsetDisease OnsetP

aO2

or

PaC

O2

PaO

2 o

r P

aCO

2

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.


Arterial Blood GasesArterial Blood Gases

Severe Flail ChestSevere Flail Chest

Acute ventilatory failure with hypoxemiaAcute ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)

pH PaCO2 HCO3- PaO2

(Slightly)


Time and Progression of DiseaseTime and Progression of Disease

100100

5050

3030

80

0

PaO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO 2

Acute Ventilatory Failure Acute Ventilatory FailureDisease OnsetDisease Onset

Point at which disease becomes severe and patient begins to become fatigued

Point at which disease becomes severe and patient begins to become fatigued

Pa0

2 o

r P

aC0 2

Pa0

2 o

r P

aC0 2

Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.


Oxygenation IndicesOxygenation Indices

QS/QT DO2 VO2 C(a-v)O2

Normal (severe)

O2ER SvO2

QS/QT DO2 VO2 C(a-v)O2

Normal (severe)

O2ER SvO2


Hemodynamic Indices Hemodynamic Indices (Severe Flail Chest)(Severe Flail Chest)

CVP CVP RAPRAP PAPA PCWPPCWP

COCO SVSV SVISVI CICI

RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR


Radiologic FindingsRadiologic Findings

Chest radiographChest radiograph

Increased density Increased density

Rib fracturesRib fractures


Figure 21-4. 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).


General Management of General Management of Flail ChestFlail Chest

Mild casesMild cases

Medication for pain and routine bronchial Medication for pain and routine bronchial hygienehygiene

Severe casesSevere cases

Volume-controlled ventilation with PEEPVolume-controlled ventilation with PEEP 5 to 10 days usually adequate for sufficient bone 5 to 10 days usually adequate for sufficient bone

healinghealing


General Management of General Management of Flail ChestFlail Chest

Respiratory care treatment protocolsRespiratory care treatment protocols

Oxygen therapy protocolOxygen therapy protocol

Hyperinflation therapy protocolHyperinflation therapy protocol

Mechanical ventilation protocolMechanical ventilation protocol


Classroom DiscussionClassroom DiscussionCase Study: Flail ChestCase Study: Flail Chest

copyright © 2006 by mosby, inc. slide 1 part v chest and pleural trauma

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