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Chapter 21
Flail Chest
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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.
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Anatomic Alterations of the Lungs
Double fracture of numerous adjacent ribs
Rib instability
Lung restriction
Atelectasis
Lung collapse (pneumothorax)
Lung contusion
Secondary pneumonia
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Etiology
Motor vehicle accident
Falls
Blast injury
Direct compression by a heavy object
Industrial accident
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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
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Clinical Data Obtained at the
Patient’s Bedside
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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 21-3.
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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
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Figure 21-2. Lateral flail chest with accompanying pendelluft.
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Figure 21-3. Venous admixture in flail chest.
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The Physical Examination
Vital Signs (Cont’d) Increased
• Heart rate (pulse)
• Blood pressure
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The Physical Examination
Cyanosis
Chest Assessment Findings Diminished breath sounds—on both the affected
and the unaffected sides
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Clinical Data Obtained from
Laboratory Tests and Special
Procedures
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Pulmonary Function Test FindingsModerate to Severe
(Restrictive Lung Pathophysiology)
Lung Volume & Capacity Findings
VT IRV ERV RV VC
N or
IC FRC TLC RV/TLC ratio
N
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Arterial Blood Gases(Mild to Moderate Flail Chest)
Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis)
pH PaCO2 HCO3 PaO2
(slightly)
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PaO2 and PaCO2 trends during acute alveolar hyperventilation.
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Arterial Blood Gases(Severe Flail Chest)
Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis)
pH PaCO2 HCO3 PaO2
(Slightly)
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PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
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Oxygenation Indices
QS/QT DO2 VO2 C(a-v)O2 O2ER SvO2
N (Severe)
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Hemodynamic IndicesSevere Flail Chest
CVP RAP PA PCWP CO SV
SVI CI RVSWI LVSWI PVR SVR
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Radiologic Findings
Chest radiograph Increased opacity
Rib fractures
Increased density on the affected side
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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).
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Respiratory Care Treatment
Protocols
In mild cases:
Medication for pain and routine bronchial
hygiene
Severe cases
Volume-controlled ventilation with PEEP 5 to 10 days usually adequate for sufficient bone
healing
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Respiratory Care Treatment
Protocols (Cont’d)
Oxygen Therapy Protocol
Lung Expansion Therapy Protocol
Mechanical Ventilation Protocol