Flail chest and pulmonary contusion

Question 1

What is the definition of flail chest?

Answer 1

fracture of two or more ribs in two or more places, resulting in an area of chest wall losing bony continuity with the thoracic cage and compromising mechanical ventilation

Question 2

What is a flail segment of the chest wall associated with?

Answer 2

significant injury to the underlying lung and pulmonary contusion

Question 3

What are the 3 means by which a flail chest causes deterioration of the patient?

Answer 3

1. pain from multiple rib fractures preventing inspiratory effort
2. underlying pulmonary contusion
3. paradoxical movement of the chest wall reducing tidal volume

Question 4

What type of mechanism of injury is likely to cause flail chest?

Answer 4

blunt injury or compression of the chest e.g. crush injury

Question 5

What are 4 clinical features of flail chest?

Answer 5

1. chest wall swelling, fractured ribs with crepitus
2. reduced movement of chest on injured side, secondary to pain
3. paradoxical movement may not be immediately apparent as splinting will initially occur from the chest wall muscle spasm
4. tachypnoea and hypoxia

Question 6

What are 2 key investigations to perform for flail chest?

Answer 6

1. Chest x-ray
2. CT scan

Question 7

What is a limitation of CXR in flail chest?

Answer 7

may not demonstrate all fractures reliably

Question 8

What is the purpose of performing a CT scan in flail chest?

Answer 8

to identify underlying lung injury

Question 9

What are 6 aspects of the management of flail chest?

Answer 9

1. supplementary oxygen
2. IV analgesia
3. judicious fluid replacement to prevent overloading of the injured lung
4. ABG to determine the need for RSI and mechanical ventilation
5. contact ICU for advice regarding ongoing management, e.g. analgesia and need for ventilation. most pts with flail chest will require minimum of HdU care
6. operative stabilisation of fractures rarely performed

Question 10

What are 3 possible complications of flail chest?

Answer 10

1. Respiratory failure
2. Underlying lung injury
3. Pneumonia

Question 11

What are 2 possible situations when flail chest may be more likely to go undetected?

Answer 11

1. Posterior flail when patient is supine
2. Large anterior flail chest where chest wall movements appear symmetrical

Question 12

What is the best place to see anterior and lateral paradoxical movements of the chest wall in flail chest?

Answer 12

eyeball supine patient from the end of bed (may not be seen when standing next to patient)

Question 13

What is a pulmonary contusion?

Answer 13

injury to the lung parenchyma resulting in blood in the alveolar spaces, oedema and loss of normal lung function

Question 14

What type of injury are associated with pulmonary contusion?

Answer 14

high energy blunt chest injury; associated with rib fractures or flail chest

also in blast injury with no external chest wall signs

Question 15

In which age group is pulmonary contusion more common?

Answer 15

children

Question 16

What are 3 clinical features of pulmonary contusion?

Answer 16

1. Associated bruising to the chest wall, rib fractures, or flail chest
2. Mild hypomobility of the chest on the affected side
3. Non-specific crepitations or reduced air entry on auscultation

Question 17

What are 2 key investigations to perform in suspected pulmonary contusions?

Answer 17

1. CXR
2. CT scan

Question 18

What will a CXR show in pulmonary contusion?

Answer 18

non-specific patchy opacification, sometimes difficult to differentiate from haemothorax or aspiration

Question 19

What 2 things can pulmonary contusinon on CXR sometimes be difficult to distinguish it from?

Answer 19

1. Haemothorax
2. Aspiration

Question 20

What is a disadvantage of using CXR to investigate pulmonary contusion?

Answer 20

sometimes lags 24-48h behind the clinical picture

Question 21

What are the advantages of performing a CT scan in suspected pulmonary contusion?

Answer 21

• very sensitive in detecting pulmonary contusion
• can differentiate from atelectasis or aspiration

Question 22

What may be the conclusion if pulmonary contusinos are detected on CT scan only?

Answer 22

may not be clinically significant to cause respiratory problems

Question 23

What are 6 aspects of the management of pulmonary contusions?

Answer 23

1. Supplemental oxygen
2. Analgesia
3. Chest physiotherapy
4. Maintain euvolaemia
5. Serial ABGs and close monitoring to detect any respiratory deterioration
6. RSI and mechanical ventilation for respiratory failure

Question 24

What are 4 possible complications of pulmonary contusions?

Answer 24

1. ARDS
2. Respiratory failure
3. Atelectasis
4. Pneumonia