island emt Posted November 1, 2010 Share Posted November 1, 2010 Seen it many times in motorcycle racers , jet skiers, snowmobilers & skiers. Severe blunt force trauma to the chest wall, usually at high speed and hitting fixed objects like handlebars, guardrails or trees. Most are not this obvious, you will generally see the paradoximal movement when their are bilateral complete fractures that are only stabilized by muscle tissue and ligaments. This guy is in deep doo doo. I'd be looking for a pneumo, hemo , or tension pneumo underlying and possibly cardiac contusions. Possible underlying organ contusions / lacerations are also a high probability. I'll stop here and let others play. Nice find on the video Link to comment Share on other sites More sharing options...
mobey Posted November 1, 2010 Share Posted November 1, 2010 Seen it many times in motorcycle racers , jet skiers, snowmobilers & skiers. Severe blunt force trauma to the chest wall, usually at high speed and hitting fixed objects like handlebars, guardrails or trees. I'll second that. Quads, and unrestrained drivers top the list in these parts too. Also saw a good one in a gentleman who fell from a powerpole Link to comment Share on other sites More sharing options...
DwayneEMTP Posted November 1, 2010 Author Share Posted November 1, 2010 Seen it many times in motorcycle racers , jet skiers, snowmobilers & skiers. Severe blunt force trauma to the chest wall, usually at high speed and hitting fixed objects like handlebars, guardrails or trees. Most are not this obvious, you will generally see the paradoximal movement when their are bilateral complete fractures that are only stabilized by muscle tissue and ligaments. This guy is in deep doo doo. I'd be looking for a pneumo, hemo , or tension pneumo underlying and possibly cardiac contusions. Possible underlying organ contusions / lacerations are also a high probability. I'll stop here and let others play. Nice find on the video Bless you IE, but did you get the part about letting the BLS and new ALS take some shots? Link to comment Share on other sites More sharing options...
fakingpatience Posted November 2, 2010 Share Posted November 2, 2010 What is flail chest? What caused it? What are your primary short term concerns? Longer term concerns? Load and go/stay and play? Why? Treatment? Please folks, if you know all of the above answers, please don't ruin it for those that can learn by asking and exploring. We already know you're smart. To the rest that are familiar with this, please feel free to jump into this thread in a mentor-ish way and help it move along if you would. I have no info on this patient so we're going to deal with him in gross terms only, OK? Dwayne Ok, I guess I will take a stab at the questions What is flail chest? If I am remembering my textbook answer correctly (no I am not looking!) when two or more (or is it 3 or more) ribs are broken in two or more places What caused it? As others have said, major trauma to the chest What are your primary short term concerns? A broken rib puncturing the lung, causing a pneumothorax (I am not really clear as to the differences between a regular pnumo and a tension pnumo, but I know both are bad). Or hemothorax, or hemopneumothorax... either way, not good. How possible is it for the fractured ribs to actually damage the heart? I would assume if it is in the right place, on a relatively skinny person it could, which would be bad bad bad. So pretty much my main short term concerns are breathing problems Longer term concerns? Um, complications from above? Load and go/stay and play? Why? Treatment? I am pretty sure regardless of BLS or ALS, I would load and go. BLS there isn't a whole hell of a lot I can do for them except use the BVM if their breathing gets really bad (if I am remembering correctly, the BVM uses positive pressure ventilations, which would negate the flail chest because it would not be negative pressure on inhalation, so the entire chest would expand w/ every breath). We don't have x-ray/ MRI vision in the field, so although we can guess, we can't know for sure what all damage is done beneath the skin on this guy. Whatever caused the force strong enough to break multiple ribs is going to put me on high alert for other injuries (not that I am triaging based on MOI, just higher index of suspicion). If he does have a punctured lung, he needs a chest tube, and while ALS providers could do a chest decompression in the field, I am pretty sure that is only a temporary fix. Either way, this guy probably needs surgical interventions (is a chest tube officially a surgery, since it is often done in the ER?) Link to comment Share on other sites More sharing options...
scubanurse Posted November 2, 2010 Share Posted November 2, 2010 Longer term concerns? Um, complications from above? Load and go/stay and play? Why? Treatment? I am pretty sure regardless of BLS or ALS, I would load and go. BLS there isn't a whole hell of a lot I can do for them except use the BVM if their breathing gets really bad (if I am remembering correctly, the BVM uses positive pressure ventilations, which would negate the flail chest because it would not be negative pressure on inhalation, so the entire chest would expand w/ every breath). We don't have x-ray/ MRI vision in the field, so although we can guess, we can't know for sure what all damage is done beneath the skin on this guy. Whatever caused the force strong enough to break multiple ribs is going to put me on high alert for other injuries (not that I am triaging based on MOI, just higher index of suspicion). If he does have a punctured lung, he needs a chest tube, and while ALS providers could do a chest decompression in the field, I am pretty sure that is only a temporary fix. Either way, this guy probably needs surgical interventions (is a chest tube officially a surgery, since it is often done in the ER?) The one time I had seen this in the field, we put a liter bag of LR over the flail segment to act as a counter weight and stabilize the chest wall... And if I'm thinking through this correctly, even with a BVM there would be negative pressure in the chest cavity. A BVM does act on positive pressure, but the action of exhalation would create negative pressure. A chest tube is a surgical procedure as well... Remember fixing an ingrown nail could technically be considered a surgical procedure. Correct me please if I'm wrong guys... wouldn't be the first time and certainly wouldn't be the last Link to comment Share on other sites More sharing options...
mobey Posted November 2, 2010 Share Posted November 2, 2010 Correct me please if I'm wrong guys... wouldn't be the first time and certainly wouldn't be the last And if I'm thinking through this correctly, even with a BVM there would be negative pressure in the chest cavity. A BVM does act on positive pressure, but the action of exhalation would create negative pressure. Think of the lung like a balloon that can expand and "suck" air in or relax and "Blow" air out. As long as it is in relax mode, it has positive pressure in it. When it expands, it creates a negative pressure and sucks air in. That's where the BVM comes in. Rather than letting the balloon (lung) "suck" air in, we will blow it up with a BVM, hence, no negative pressure. .....field, we put a liter bag of LR over the flail segment If the pt is Cx, you may just want to offer a pillow of towel for them to "Cuddle" and splint it themselves.... Flail segments are extremely painful and Cx people will not let you near them. Link to comment Share on other sites More sharing options...
Richard B the EMT Posted November 2, 2010 Share Posted November 2, 2010 Studied it in the texts, and been in the field 38 years, and until this video was published here, never seen one! Guess some folks have all the luck. Link to comment Share on other sites More sharing options...
fakingpatience Posted November 2, 2010 Share Posted November 2, 2010 (edited) Studied it in the texts, and been in the field 38 years, and until this video was published here, never seen one! Guess some folks have all the luck. I technically had a patient with a flail chest, I think. Thats the thing that sucks about being the basic on an ALS ambulance. Our guy had major crush injuries and needed to be at the trauma center, so as soon as he was extricated, we loaded him into the ambulance, and I drove to the trauma center. I asked my partner about it after the call, but its still not the same as being back there with the patient. Can't wait till I'm the medic in the back (2 more years...) Anyway, the pt ended up having 6+broken ribs, and a small pneumo (my partner and the other medic in the back didn't realize he had a pneumo), but wouldn't even tolerate a pillow splint for his ribs. Edited November 2, 2010 by fakingpatience Link to comment Share on other sites More sharing options...
uglyEMT Posted November 2, 2010 Share Posted November 2, 2010 Well as a BLS I will shoot at it Flail chest is 3 or more ribs that are broken and only held in place by the ligaments and muscles of the chest wall. How do I fix it? Pressure, Pressure, Pressure. Either with my hand, a sand bag, anything to keep pressure on the segment. Short term concerns? Punctured lung, tension pneumo or pneumothorax. This is definatly an ALS call. I would load and go and contact my ALS via radio for a line of sight meet up. No playing around with this patient, we are looking at a multi system trauma and really in the field we have no way of telling the extent of the internal damage. If a Level 1 is too far out I would actually call for a bird! Long Term? Well I would think pnemonia. I am not a doctor so diagnosis isnt in my SOP Kidding LOL I would think pain managment, surgical response to the flail, and infection at the site of the chest tube. I have only seen one in my time as a BLS, caused by blunt force trauma from an unrestrained passenger and a dash board meeting during a telephone pole interview Link to comment Share on other sites More sharing options...
Bieber Posted November 2, 2010 Share Posted November 2, 2010 (edited) I've only seen one possible flail chest segment so far, and it was really, really wild. It was an older patient restrained front seat passenger of a car that went off the road and into the ditch (actually it landed so that the front and back bumpers were suspended on both edges of a drainage ditch with the rest of the car suspended about three or four feet above the ditch itself) with no airbag deployment who was a little banged up and complaining of some difficulty breathing. It actually looked like they had either bilateral flail segments or a floating sternum, they had bilateral paradoxical chest wall motion that moved concurrently and equally with respect to the other side and opposite of the sternum, which itself appeared to be moving anteriorly outward from their chest with each breath. The patient did fine during transport with some minimal relief from the NRB, alert and oriented x3 throughout the trip, clear and equal breath sounds, good pressures, sinus tachycardia with frequent unifocal PVC's, no 12 lead changes. The chest wall motion was about as dramatic as in your video, Dwayne. We boarded them, plus IV, O2 and monitor (switching back and fourth between patient number one and the driver). Edited November 2, 2010 by Bieber Link to comment Share on other sites More sharing options...
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