1 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 21 Flail Chest

2 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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.

3 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Anatomic Alterations of the Lungs   Double fracture of numerous adjacent ribs   Rib instability   Lung restriction   Atelectasis   Lung collapse (pneumothorax)   Lung contusion   Secondary pneumonia

4 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Etiology   Motor vehicle accident   Falls   Blast injury   Direct compression by a heavy object   Industrial accident

5 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

6 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

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8 Clinical Data Obtained at the Patient’s Bedside

9 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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.

10 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

11 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Lateral flail chest with accompanying pendelluft.

12 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Venous admixture in flail chest.

13 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination  Vital Signs (Cont’d)  Increased Heart rate (pulse) Blood pressure

14 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination  Cyanosis  Chest Assessment Findings  Diminished breath sounds—on both the affected and the unaffected sides

15 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained from Laboratory Tests and Special Procedures

16 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

17 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases (Mild to Moderate Flail Chest) Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) pH PaCO 2 HCO 3 PaO 2    (slightly) 

18 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute alveolar hyperventilation.

19 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases (Severe Flail Chest) Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis) pH PaCO 2 HCO 3 PaO 2    (Slightly) 

20 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

21 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Oxygenation Indices Q S /Q T DO 2 VO 2 C(a-v)O 2 O 2 ER SvO 2   N  (Severe)  

22 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Hemodynamic Indices Severe Flail Chest CVP RAP PA PCWP CO SV       SVI CI RVSWI LVSWI PVR SVR      

23 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Radiologic Findings  Chest radiograph  Increased opacity  Rib fractures  Increased density on the affected side

24 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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).

25 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

26 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Care Treatment Protocols (Cont’d)  Oxygen Therapy Protocol  Lung Expansion Therapy Protocol  Mechanical Ventilation Protocol