Management of Flail Chest Without Mechanical Ventilation

From the Departments of Surgery and Anesthesiology, The University of Texas Health Science Center at San Antonio, San Antonio, Tex.
The Annals of Thoracic Surgery (Impact Factor: 3.85). 05/1975; 19(4):355-63. DOI: 10.1016/S0003-4975(10)64034-9
Source: PubMed


The pathophysiology of flail chest is usually described only on the basis of paradoxical respiration, ignoring underlying pulmonary contusion. Two groups of comparable patients were treated either with early tracheal intubation and mechanical ventilation (Group 1), or with fluid restriction, diuretics, methylpredinisolone, albumin, vigorous pulmonary toilet, and intercostal nerve blocks, ignoring the paradox and treating only the underlying lung (Group 2). When tracheostomy and mechanical ventilation were not used the mortality rate went from 21% to O(p = 0.01), the complication rate from 100% to 20% (p = 0.005), and the average hospitalization from 31.3 to 9.3 days (p = 0.005). We conclude that most patients with flail chest do not need internal pneumatic stabilization if the underlying lung is treated appropriately and that tracheostomy and prolonged mechanical ventilation with a volume respirator, as practiced in most respiratory care centers, is usually a triumph of technique over judgment.

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    • "Approximately one out of 13 patients with fractured ribs admitted to a hospital will have flail chest with reported mortality rates averaging 10 – 20% [5] [6]. Although there have been many advances in the management of major chest injuries, flail chest continues to be an important injury with significant complications because the paradoxical chest movement causes a decrease in the vital capacity and ineffective ventilation resulting in pulmonary insufficiency [1] [5] [6]. "
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    ABSTRACT: Flail chest continues to be an important injury with significant complications. The records of 150 patients presenting with flail chest injury were reviewed to determine risk factors affecting morbidity and mortality. During a 7-year period 150 patients with a flail chest injury were admitted to our trauma center. There were 111 men (74%) and 39 women (26%) ranging in age from 18 to 88 years with a mean age of 56.9. Only 66 (44%) had an isolated flail chest injury on admission. The majority of patients were older than 55 years (n = 89, 59.3%), 80 (53.3%) presented with an hemo-, or/and pneumothorax, 36 (24%) sustained a head injury and 25 (16.7%) needed ICU monitoring. The mean ISS score was 38. Age, concomitant diseases, presence of pneumothorax and/or hemothorax, Severity Score (ISS), the need for mechanical support, length of stay and deaths were evaluated by using the t-test and chi2 test where appropriate. Sixty-seven patients (44.6%) were conservatively treated, while 80 (53.3%) needed thoracic drainage. Only in 6 cases (4%) thoracotomy was required, while in 9 (6%) laparotomy was performed. Mortality rate reached 5.3%. The main factors correlated with an adverse outcome were: ISS and the presence of associated injuries, while age, hemopneumothorax and mechanical support affected the length of hospitalization but not the mortality. (1) Age and hemopneumothorax did not affect mortality. (2) ISS was found to a strong predictor on outcome concerning morbidity and prolonged hospitalization but did not influence mortality rate. (3) Mechanical support was not considered a necessity for the treatment of flail chest.
    European Journal of Cardio-Thoracic Surgery 09/2004; 26(2):373-6. DOI:10.1016/j.ejcts.2004.04.011 · 3.30 Impact Factor
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    • "Patients with pulmonary contusion require aggressive cardiorespiratory monitoring, supplemental oxygen, and careful observation. Early aggressive pulmonary toilet is crucial in reducing the need for mechanical ventilation because there is no benefit in prophylactic intubation [36]. In patients who are managed with endotracheal intubation with mechanical ventilatory support, the use of positive end-expiratory pressure during mechanical ventilation is crucial. "
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    ABSTRACT: Pulmonary trauma is a significant cause of morbidity and mortality in the United States. It is imperative for the emergency physician to identify promptly patients who require immediate therapy. In patients who have limited injuries, literature shows that often conservative management provides improved outcome. As the exposure to automobiles and firearms continues to increase in the setting of improved prehospital management, the emergency physician will encounter an increasing amount of pulmonary trauma. This rise in respiratory injuries will require a more aggressive approach of patients with minimal morbidity and mortality. A systematic approach to respiratory injuries is crucial to improving patient outcomes.
    Emergency Medicine Clinics of North America 06/2003; 21(2):291-313. · 0.78 Impact Factor
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    • "the costochondral junction which cannot be demonstrated radiographically), producing an unstable segment which underwent paradoxical movement on respiration. This unit followed a conservative policy in the management of patients with flail chest injuries, Trinkle et al. (1975), Shackford et al. (1976 & 1981), Richardson et al. (1982). "
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    ABSTRACT: Two hundred and fifty patients with chest trauma admitted consecutively over a 6-year period to the Royal Surrey County Hospital were reviewed. This is a large series by British standards. The cause and nature of their chest and associated injuries were studied, together with the management, complications and outcome. The aim of this study was to find areas where diagnosis and treatment could be improved. It was found that where there was no lung contusion, flail chest injuries could be managed without ventilation. The review suggests that even small traumatically induced pneumothoraces should be drained. It illustrates the need for an awareness of the wide range of concurrent problems in patients with chest injuries and the variety of possible complications.
    Archives of emergency medicine 07/1989; 6(2):97-106. DOI:10.1136/emj.6.2.97
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