A flail chest is a severe injury to the chest wall caused by multiple rib fractures and sternal injuries that may occur as a result of high-speed motor vehicle accidents or motorcycle accidents. It is caused from a high impact force to the chest wall when the injured person is hurled into the ground or the dashboard at high speeds. This injury is a life-threatening condition because the chest wall collapses on inspiration (breathing in) rather than expanding reducing lung function that often leads to respiratory failure. Complicating matters is that the flail chest injury is nearly always associated with multiple associated injuries including traumatic brain injury, pulmonary contusions, pelvic fractures, and abdominal injuries. Over half of patients with flail chest injuries will be expected to require mechanical ventilation for over a week.
Treatment of the flail chest will either be non-surgical versus surgical and may depend on the skill, training, and capabilities of the trauma center. Surgical management involves stabilizing the fractured ribs of the chest wall with plates or mesh allowing for the lungs to expand during inspiration rather than the situation where the chest wall collapses during inspiration preventing lung expansion in the case of the flail chest. Studies have attempted to determine the best management for this injury, surgical versus non-surgical, but the diversity of injuries to the lung and other associated injuries makes it difficult for a true comparison in outcomes.
Many experts believe it is not the degree of bony injury to the chest wall, but the severity of the pulmonary contusions that determines the ultimate outcome. A pulmonary contusion is an injury to the lung causing bleeding and edema (swelling) that leads to loss of normal lung function. Many in the trauma field believe that the degree of pulmonary contusions should dictate the decision regarding surgical versus conservative management of the flail chest. A study supports this view by showing that patients with a flail chest and no evidence of pulmonary contusions have a better outcome if operated on early to stabilize the chest, while patients with a flail chest and pulmonary contusion should only undergo operative management if there is evidence of progressive collapse of the lung inside the chest wall despite mechanical ventilation.
Other studies favor operative management for patients with a flail chest by evidence demonstrating that the numbers of days these patients required on the ventilator, rates of chest infection, and number of days in the ICU decrease with operative management compared with non-operative management. Long-term outcomes appear to indicate that operative management reduces long-term pain, deformity of the chest wall, and disability with improved pulmonary function tests compared to non-operative management six months following trauma.
Ultimately that chosen path regarding operative versus non-operative management for a critically injured patient with a flail chest and multiple other life-threatening injuries will be a clinical decision made by the trauma and thoracic surgeons based on their skill and experience. Studies are conflicting and simply do not provide the compelling evidence for surgical versus non-surgical management. The injuries to the thorax and associated injuries are too diverse to make a firm standard of care.
Case Managers must understand that patients with a flail chest often remain at risk for pneumonia, atelectasis (collapse lung), and acute respiratory failure well after their transfer out of the ICU to rehabilitation hospitals because of impairments in inspiration and decreased ability to clear secretions (cough up sputum). They often have a tracheostomy and impaired swallowing that places them at risk for aspiration pneumonia. These patients need rehabilitation at facilities with on site respiratory therapists, x-ray, daily physician evaluations, and pulmonologists on staff to monitor the injured person and timely identify complications.
Academic Physician Life Care Planners are in the best position to understand the impact of a flail chest on the overall function of the injured. Studies indicate patient with a flail chest managed without surgery have impaired pulmonary function related to restriction in chest wall expansion and have shortness of breath with normal activities required to be independent. There likely will be concomitant injuries such as traumatic brain injuries and post-traumatic arthritis that increase the energy requirement for walking that when coupled with the decreased respiratory function will cause disability. The individualized Academic Physician Life Care Plan must account for the interactions between disabling injuries to ensure all necessary and appropriate medical and non-medical service and good are provided for to decrease complications and maintain the overall psychosocial health of the injured person.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1493106/pdf/annsurg00198-0094.pdf
http://icvts.oxfordjournals.org/content/4/6/583.full
Press Contact
Dr. Greg Vigna, MD, JD
T: 800-761-9206
https://www.lifecare123.com
Connect with Dr. Greg Vigna, MD, JD
on Facebook, Twitter, or Google+
#DrGregVigna
News Provided By: Submit Press Release 123
