Flail Chest – Have you ever wondered how the chest is affected after being crushed by the steering wheel during a major car accident? If so, read the details below.
What is a Flail Chest?
● A flail chest is a medical emergency caused by severe blunt trauma to the ribs and chest in multiple areas.
● A flail chest is the abnormal inward movement of a section of the chest wall caused by more than three rib fractures anteriorly (front) and posteriorly (back) within each rib.
o There are multiple flail chest variations: posterior flail segments, anterior flail segments, and flail sternum with ribs on both sides of the thoracic cage fractured that may cause heart and lung damage
● Trauma can be caused by MVA (rollover injury or crash), falls, and assaults in younger, healthier, patients.
● Flail chest injuries are often accompanied by pulmonary contusions, hemopneumothorax, heart injury, and an occasional major vascular injury.
● Patients who do not need mechanical ventilation do better.
● Mortality (death rate) increases with the increase of injury severity, age, and total number of rib fractures.
Diagnosis
● An indicator of a flail chest is when a part of the chest wall moves separately from the rest of the chest wall. Flail chest is often unilateral (on one side) but can be bilateral (both sides).
● Patients who are suspected of having a flail chest will be worked-up in the ER by having X-rays with a rib series and a sagittal and coronal view of the thoracic spine by a multi-slice computed tomography (MSCT) scan of the chest to assess for rib fractures.
● A decline in respirations because of a flail chest is caused by severe pulmonary contusions (bruised lungs) that damage the chest wall.
● There is a 5% to 10% mortality rate if patients reach the hospital alive.
● Blood work will include Arterial Blood Gases (ABGs) to assess the severity of hypoventilation caused by a possible pulmonary contusion (lung bruise) and the pain caused by the rib fractures.
● The results of the work-up will help decide the need for mechanical ventilation.
● Mechanical ventilation is used for patients who have persistent respiratory insufficiency, failure after adequate pain control, or complications related to excessive narcotic administration occur.
Treatment
● Medical treatment will require adequate pain control and management of the pulmonary injury prior to being placed on mechanical ventilation.
● Surgical treatment typically requires an operative fixation.
o An operative fixation is determined by the severity of the underlying pulmonary contusion versus chest wall instability, multiple myeloma, sternal absence, or total sternotomy.
o An operative fixation is commonly performed on patients that need a thoracotomy for other reasons or gross chest wall deformity.
A flail chest diagnosed in children is a potential sign of child abuse. Please follow-up with a pediatrician, family physician, or nearest ER as soon as possible. If you suspect that the child may be in danger, please call the police and child protective services.
References
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VectorMine. (2020). [Illustration Diagram]. Rib cage anatomy, labeled vector illustration diagram. Medical human chest skeletal bone structure model. Numbered ribs, sternum, cartilage parts and clavicular articulation. Health care education. Retrieved from https://www.shutterstock.com/image-vector/rib-cage-anatomy-labeled-vector-illustration-1650017491.