Flail Chest: Difference between revisions
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'''Jennifer Lohmus ''' | '''Jennifer Lohmus ''' | ||
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== | == Muscles of Respiration == | ||
Refer to the Physiopedia page below for clinically relevant anatomy and how the muscles involved in breathing mechanics operate | |||
[[Muscles of Respiration]]<br> | |||
== Pathophysiology == | == Pathophysiology == | ||
“A break in the structural continuity of the bone” that can be caused by trauma, stress and pathological factors. (Apley, Solomon, Warwick, Nayagam & Apley, 2005) | “A break in the structural continuity of the bone” that can be caused by trauma, stress and pathological factors." (Apley, Solomon, Warwick, Nayagam & Apley, 2005) | ||
Types: | Types: | ||
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* Incomplete | * Incomplete | ||
* Physeal | * Physeal | ||
Classification according to the nature of the fracture: | '''Classification''' according to the nature of the fracture: | ||
* Spiral | * Spiral | ||
* Transverse | * Transverse | ||
| Line 20: | Line 21: | ||
== Associated conditions: == | == Associated conditions: == | ||
Pulmonary complications 48-72 hours after admission (Battle, Hutchings, James, & Evans, 2013): | '''Pulmonary complications''' 48-72 hours after admission (Battle, Hutchings, James, & Evans, 2013): | ||
* haemothorax | * haemothorax | ||
* pneumothorax | * pneumothorax | ||
| Line 31: | Line 32: | ||
* aspiration | * aspiration | ||
* lobar collapse | * lobar collapse | ||
Risk factors for developing associated conditions (Battle, Hutchings, James, & Evans, 2013): | '''Risk factors''' for developing associated conditions (Battle, Hutchings, James, & Evans, 2013): | ||
* >65 years old | * >65 years old | ||
* >3 rib fractures | * >3 rib fractures | ||
| Line 40: | Line 41: | ||
== Clinical Presentation == | == Clinical Presentation == | ||
A flail segment is a portion of the rib cage that breaks due to trauma and becomes unattached from the chest wall. (Pettiford, Luketich & Landreneau, 2007). Generation of negative intrapleural pressure indicates a true paradoxical flail segment (May, Hillermann & Patil, 2015). | |||
== Diagnostic Procedures == | == Diagnostic Procedures == | ||
Radiologists use Chest X-Rays to look for the following: | |||
“Three or more adjacent ribs are fractured in two or more places. Clinically this can be a segment of only one or two ribs can act as a flail segment” (Stanislavsky, 2018).<br> | |||
== Outcome Measures == | == Outcome Measures == | ||
| Line 54: | Line 57: | ||
== Physiotherapy Management / Interventions == | == Physiotherapy Management / Interventions == | ||
Chest physiotherapy management consists of the following | Chest physiotherapy management consists of the following: | ||
1. Ventilatory Management - supplemental oxygen therapy, continuous positive airway pressure or intubation if necessary | 1. Ventilatory Management - supplemental oxygen therapy, continuous positive airway pressure or intubation if necessary (May, Hillermann & Patil, 2016) | ||
* CPAP - for negative intrapleural pressure and paradoxical movement, increases TV (May, Hillermann & Patil, 2015) | * CPAP - for negative intrapleural pressure and paradoxical movement, increases TV (May, Hillermann & Patil, 2015) | ||
* Open/closed suction if patient intubated (Berney, Haines & Denehy, 2012) | * Open/closed suction if patient intubated (Berney, Haines & Denehy, 2012) | ||
2. Pain Management and Education | 2. Pain Management and Education (May, Hillermann & Patil, 2016) | ||
* Education on fracture healing | * Education on fracture healing | ||
3. Early mobilization if possible | 3. Early mobilization if possible (May, Hillermann & Patil, 2016) | ||
* Transfers to sitting out of bed | * Transfers to sitting out of bed | ||
* Mobilization 2-3x daily and SOOB 3-4x/day | * Mobilization 2-3x daily and SOOB 3-4x/day | ||
4. Chest and airway clearance techniques (if inadequate) | 4. Chest and airway clearance techniques (if inadequate) (May, Hillermann & Patil, 2016) | ||
* ACT: nebulizer with ACBT and education | * ACT: nebulizer with ACBT and education | ||
* Bubble PEP or Flutter | * Bubble PEP or Flutter | ||
5. Deep breathing exercises and supported coughing technique | 5. Deep breathing exercises and supported coughing technique (May, Hillermann & Patil, 2016) | ||
* Supported Cough: Wrap around technique or rolled up towel | * Supported Cough: Wrap around technique or rolled up towel | ||
* DBE/TEE’s with SMIs (2-4 secs hold) | * DBE/TEE’s with SMIs (2-4 secs hold) | ||
6. Positioning | 6. Positioning (Berney, Haines & Denehy, 2012) | ||
* Positioning in side lying and high sitting | * Positioning in side lying and high sitting | ||
== Medical Management == | == Medical Management == | ||
Medications: (May, Hillermann & Patil, 2016) | '''Medications''': (May, Hillermann & Patil, 2016) | ||
# Simple Analgesics | # Simple Analgesics | ||
# Opioids | # Opioids | ||
| Line 80: | Line 83: | ||
# Operative fixation and Regional Anaesthetic | # Operative fixation and Regional Anaesthetic | ||
Surgery: | '''Surgery''': | ||
Conservative (May, Hillermann & Patil, 2016) | ''Conservative'' (May, Hillermann & Patil, 2016) | ||
* Regional anaesthesia | * Regional anaesthesia | ||
* Serratus anterior block | * Serratus anterior block | ||
* Paravertebral block | * Paravertebral block | ||
* Thoracic epidural | * Thoracic epidural | ||
''Internal fixation'' (May, Hillermann & Patil, 2015) | |||
* Decreases stay in ICU and MV duration (Leinicke et al., 2013) | |||
* Similar to thoracotomy but incision but spares Latissimus Dorsi | |||
* Anterior # - plates and locking screws | |||
* Posterior # - intramedullary splints<br> | |||
== Resources == | == Resources == | ||
| Line 102: | Line 106: | ||
Battle C, Hutchings H, Evans PA. Blunt chest wall trauma: A review. Trauma. 2013;15(2):156-75. | Battle C, Hutchings H, Evans PA. Blunt chest wall trauma: A review. Trauma. 2013;15(2):156-75. | ||
Berney S, Haines K, Denehy L. Physiotherapy in Critical Care in Australia. Cardiopulmonary Physical Therapy. 2012;23(1):19-25. | |||
Jena R, Agrawal A, Sandeep Y, Shrikhande N. Understanding of flail chest injuries and concepts in management. International Journal of Studentsí Research. 2016;6(1):3-5. | Jena R, Agrawal A, Sandeep Y, Shrikhande N. Understanding of flail chest injuries and concepts in management. International Journal of Studentsí Research. 2016;6(1):3-5. | ||
Leinicke AJ, Elmore DL, Freeman AB, Colditz AG. Operative Management of Rib Fractures in the Setting of Flail Chest: A Systematic Review and Meta-Analysis. Annals of Surgery. 2013;258(6):914-21. | |||
May L, Hillermann C, Patil S. Rib fracture management. BJA Education. 2016;16(1):26-32. | May L, Hillermann C, Patil S. Rib fracture management. BJA Education. 2016;16(1):26-32. | ||
| Line 110: | Line 118: | ||
Solomon L. Apley's concise system of orthopaedics and fractures. 3rd ed.. ed. Warwick D, Nayagam S, Apley AG, editors. London : New York: London : Hodder Arnold New York : Distributed in the United States by Oxford University Press; 2005. | Solomon L. Apley's concise system of orthopaedics and fractures. 3rd ed.. ed. Warwick D, Nayagam S, Apley AG, editors. London : New York: London : Hodder Arnold New York : Distributed in the United States by Oxford University Press; 2005. | ||
Stanislavsky A. Radiology Reference Article. Flail chest. <nowiki>https://radiopaedia.org/articles/flail-chest</nowiki> (accessed 15 June 2018). | |||
Revision as of 11:30, 15 June 2018
Jennifer Lohmus
Muscles of Respiration[edit | edit source]
Refer to the Physiopedia page below for clinically relevant anatomy and how the muscles involved in breathing mechanics operate
Pathophysiology[edit | edit source]
“A break in the structural continuity of the bone” that can be caused by trauma, stress and pathological factors." (Apley, Solomon, Warwick, Nayagam & Apley, 2005)
Types:
- Complete
- Incomplete
- Physeal
Classification according to the nature of the fracture:
- Spiral
- Transverse
- Comminuted
- Compression
Associated conditions:[edit | edit source]
Pulmonary complications 48-72 hours after admission (Battle, Hutchings, James, & Evans, 2013):
- haemothorax
- pneumothorax
- atelectasis
- pneumonia
- pleural effusion
- subcutaneous emphysema
- ARDS,
- pulmonary emboli
- aspiration
- lobar collapse
Risk factors for developing associated conditions (Battle, Hutchings, James, & Evans, 2013):
- >65 years old
- >3 rib fractures
- Hx. of chronic lung conditions or CVD
- Pre-injury anti-coagulant use
- <90% SpO2
Clinical Presentation[edit | edit source]
A flail segment is a portion of the rib cage that breaks due to trauma and becomes unattached from the chest wall. (Pettiford, Luketich & Landreneau, 2007). Generation of negative intrapleural pressure indicates a true paradoxical flail segment (May, Hillermann & Patil, 2015).
Diagnostic Procedures[edit | edit source]
Radiologists use Chest X-Rays to look for the following:
“Three or more adjacent ribs are fractured in two or more places. Clinically this can be a segment of only one or two ribs can act as a flail segment” (Stanislavsky, 2018).
Outcome Measures[edit | edit source]
Physiotherapy Management / Interventions[edit | edit source]
Chest physiotherapy management consists of the following:
1. Ventilatory Management - supplemental oxygen therapy, continuous positive airway pressure or intubation if necessary (May, Hillermann & Patil, 2016)
- CPAP - for negative intrapleural pressure and paradoxical movement, increases TV (May, Hillermann & Patil, 2015)
- Open/closed suction if patient intubated (Berney, Haines & Denehy, 2012)
2. Pain Management and Education (May, Hillermann & Patil, 2016)
- Education on fracture healing
3. Early mobilization if possible (May, Hillermann & Patil, 2016)
- Transfers to sitting out of bed
- Mobilization 2-3x daily and SOOB 3-4x/day
4. Chest and airway clearance techniques (if inadequate) (May, Hillermann & Patil, 2016)
- ACT: nebulizer with ACBT and education
- Bubble PEP or Flutter
5. Deep breathing exercises and supported coughing technique (May, Hillermann & Patil, 2016)
- Supported Cough: Wrap around technique or rolled up towel
- DBE/TEE’s with SMIs (2-4 secs hold)
6. Positioning (Berney, Haines & Denehy, 2012)
- Positioning in side lying and high sitting
Medical Management[edit | edit source]
Medications: (May, Hillermann & Patil, 2016)
- Simple Analgesics
- Opioids
- Patient Controlled Analgesia
- Operative fixation and Regional Anaesthetic
Surgery:
Conservative (May, Hillermann & Patil, 2016)
- Regional anaesthesia
- Serratus anterior block
- Paravertebral block
- Thoracic epidural
Internal fixation (May, Hillermann & Patil, 2015)
- Decreases stay in ICU and MV duration (Leinicke et al., 2013)
- Similar to thoracotomy but incision but spares Latissimus Dorsi
- Anterior # - plates and locking screws
- Posterior # - intramedullary splints
Resources[edit | edit source]
https://www.rch.org.au/trauma-service/manual/chest-injury/
https://www.wcpt.org/wcpt2017/FS-01
References[edit | edit source]
Battle C, Hutchings H, Evans PA. Blunt chest wall trauma: A review. Trauma. 2013;15(2):156-75.
Berney S, Haines K, Denehy L. Physiotherapy in Critical Care in Australia. Cardiopulmonary Physical Therapy. 2012;23(1):19-25.
Jena R, Agrawal A, Sandeep Y, Shrikhande N. Understanding of flail chest injuries and concepts in management. International Journal of Studentsí Research. 2016;6(1):3-5.
Leinicke AJ, Elmore DL, Freeman AB, Colditz AG. Operative Management of Rib Fractures in the Setting of Flail Chest: A Systematic Review and Meta-Analysis. Annals of Surgery. 2013;258(6):914-21.
May L, Hillermann C, Patil S. Rib fracture management. BJA Education. 2016;16(1):26-32.
Pettiford BL, Luketich JD, Landreneau RJ. The Management of Flail Chest. Thoracic Surgery Clinics. 2007;17(1):25-33.
Solomon L. Apley's concise system of orthopaedics and fractures. 3rd ed.. ed. Warwick D, Nayagam S, Apley AG, editors. London : New York: London : Hodder Arnold New York : Distributed in the United States by Oxford University Press; 2005.
Stanislavsky A. Radiology Reference Article. Flail chest. https://radiopaedia.org/articles/flail-chest (accessed 15 June 2018).
