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At least 19 recordsLinked to original sources
PubMed1988

Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion.

We reviewed 144 consecutive patients with flail chest and/or pulmonary contusion between 1979 and 1984. The purpose was to analyze the factors adversely affecting morbidity and mortality. There were 97 males and 47 females, with an average age of 40 years +/- 18 S.D. (range, 2-83). Seventy-five per cent of the injuries were caused by motor vehicle accidents, with the remainder due to falls (17%), cardiopulmonary resuscitation (4%), altercations (2%), or falling objects (2%). The Injury Severity Score (ISS) averaged 32 +/- 14 S.D. in all survivors versus 60 +/- 14 S.D. in those who died. Eighty-three patients (58%) required mechanical ventilation. Thirty-six patients died (25%). Isolated pulmonary contusion or flail chest had a mortality of 16% each. However, the mortality more than doubled when there was a combined pulmonary contusion and flail chest (42%). More than half of all deaths were directly attributed to central nervous system injuries with another third due to massive hemorrhage. Factors that were associated with a higher morbidity and mortality included severe associated thoracic injuries, a high ISS, the presence of shock, falls from heights, and the combination of pulmonary contusion and flail chest.

Adolescent↗
PubMed1998

Operative chest wall stabilization in flail chest--outcomes of patients with or without pulmonary contusion.

BACKGROUND: The aim of operative chest wall stabilization in patients with flail chest and respiratory insufficiency is to reduce ventilator time and avoid ventilator associated complications. The purpose of this retrospective study was to analyze the indications and outcomes of operative chest wall stabilization in defined groups of patients sustaining flail chest with and without pulmonary contusion. METHODS: The hospital records of 405 patients with multiple trauma (Injury Severity Score > 17) between 1988 and 1994 were reviewed. Forty-two patients sustained flail chest. Twenty of these underwent operative chest wall stabilization for the following indications: 1) flail chest with indication for thoracotomy due to intrathoracic injury (n = 6); 2) flail chest without pulmonary contusion (n = 9); 3) paradoxical movement of a chest wall segment in the weaning period from the respirator (n = 3); and 4) severe deformity of the chest wall (n = 2). For the purpose of analysis the patients were separated into groups: group 1: operative chest wall stabilization in flail chest without pulmonary contusion (n = 10); group 2: operative chest wall stabilization in flail chest with pulmonary contusion (n = 10); group 3: flail chest without pulmonary contusion and without chest wall stabilization (n = 18); group 4: flail chest with pulmonary contusion and without chest wall stabilization (n = 4). Data were coded for time of operation, duration of ventilatory support, and complications. RESULTS: There were no significant differences in age, severity of injury, and extent of injury between groups 1, 2, and 3 (p < 0.42). Group 4 was excluded for statistical analysis because of the small number of patients. Patients in group 1 required a shorter ventilatory support time compared to patients in group 3 (6.5+/-7.0 versus 26.7+/-29.0 days) and group 2 (p < 0.02). In group 2 (ventilator time 30.8+/-33.7 days) early extubation was only possible in patients being operated on for chest wall instability during weaning from the ventilator. One patient in group 1, three patients in group 2 and five patients in group 3 developed pneumonia with further disturbance of gas exchange. All patients in group 1 survived; deaths in group 2 were attributed to massive hemorrhage in two and septic multiorgan failure in one patient. Four patients in group 3 died of head injury, one of acute respiratory distress syndrome, one of severe hemorrhage, and one of multiple organ failure. CONCLUSIONS: In patients with flail chest and respiratory insufficiency without pulmonary contusion, operative chest wall stabilization permits early extubation. Patients with pulmonary contusion do not benefit from chest wall stabilization. Secondary operative chest wall stabilization in these patients is indicated when progressive collapse of the chest wall is evident during weaning from the ventilator.

Adult↗
PubMed1977

The treatment of flail chest injury.

Flail chest injuries are traditionally managed by long-term artificial ventilation, which in itself is hazardous and expensive. A more conservative therapeutic regime is described, and the results of this regime are compared with those following the previous traditional regime used in the Respiratory Unit, Royal Brisbane Hospital. The place of artificial ventilation in relation to spontaneous ventilation is redefined in the context of this new regime.

Humans↗
PubMed1989

Chest wall distortion in patients with flail chest.

Ventilators can impose resistive and elastic loads during subject-initiated and spontaneous breaths. Such loads might worsen the chest wall distortion that is characteristic of patients with flail chest. We have tested this expectation in nine patients with flail chest and four normal subjects. All subjects breathed for 3 to 5 min on each of the following modes: assist control, intermittent mandatory ventilation (IMV), continuous positive airway pressure 5 to 10 cm H2O by demand valve and by a high flow system (CPAP-HF), and spontaneously (T-piece). Pressure at the airway opening was evaluated as a measure of ventilator loading, and magnetometric displacements of the major chest wall dimensions were evaluated to assess chest wall distortion. In contrast to the normal volunteers, patients with flail chest displayed chest wall distortion during active inspirations. The patterns of distortion were variable among patients. The degree of distortion varied among ventilator modes; generally, there was a greater degree of chest wall distortion in breaths with greater loading. For example, distortion was greater during the spontaneous breaths taken on the IMV-mode than during spontaneous breaths taken on the T-piece. The CPAP-HF mode resulted in the least distortion, reversing chest wall distortion in five patients, improving it in two, and not changing the distortion in the remaining two. The improvements may be related to positive pleural pressures and to the minimal ventilator-imposed load of the high gas flow system. The distortion imposed by ventilators increases the work of breathing in these patients and may thus contribute to difficulty in weaning.

Aged↗
PubMed1980

Pathologic flail chest complicating multiple myeloma.

Pathologic flail chest complicated the initial presentation of multiple myeloma in two patients. Both had severe hypercalcemia and diffuse bone disease. Atelectasis and pulmonary edema preceded the appearance of flail chest in one patient; atelectasis complicated the flail chest in the second patient and increased the severity of the flail. Both were treated with radiotherapy and chemotherapy. However, delay in stabilizing the first patient's chest wall with positive airway pressure was followed by extension of the flail chest and irreversible respiratory failure. On the other hand, prolonged stabilization of the chest wall in the second patient until a chemotherapy-induced remission occurred was associated with resolution of the flail chest.

Bone Neoplasms↗
PubMed1986

Unilateral chest wall paradoxical motion mimicking a flail chest in a patient with hemilateral C7 spinal injury.

After a lower hemi-cervical spinal cord injury, a patient presented with a left hemiplegia and on the same side a unilateral chest wall paradoxical motion mimicking a flail chest. X-rays demonstrated a left hemilateral C6 injury but no rib fractures. We demonstrated that the paradoxical motion was due to the action of the diaphragm acting on the rib cage with intercostal respiratory paralysis on the side of hemiplegia.

Diagnosis, Differential↗
PubMed1996

Experimental flail chest: ventilatory function with fixation of flail segment in internal and external position.

UNLABELLED: The effect on ventilatory function of fixation of a flail segment in internal (FIP) and external (FEP) position and oxygen administration was studied in an experimental flail chest with pleural indemnity. Variations of tidal volume (TV), respiratory rate (RR), minute volume (MV), and arterial blood gases are reported. These parameters were measured in nine dogs in control and flail conditions (FC). The effect of FIP, FEP, and oxygen administration were studied. RESULTS: Significant differences were found: TV decreased from control values to FC and from FC to FIP, but increased from FC to FEP. RR values increased from control to FC and from FC to FIP, but decreased from FC to FEP. MV values decreased from FC to FEP. TV, RR, and MV were not changed under oxygen administration. Hypoxemia or hypercapnia were not observed. It was concluded that FIP is deleterious for respiratory mechanics, whereas FEP improves ventilatory parameters.

Animals↗
PubMedDate not supplied

Flail chest as a complication of cardiopulmonary resuscitation.

Records of all patients who developed flail chest after cardiopulmonary resuscitation at Rochester Methodist Hospital between January, 1966 and March 1976 were reviewed. Also, for comparison, records of patients with flail chest resulting from motor vehicle accidents and those of a matched group of patients who underwent cardiopulmonary resuscitation without developing flail chest were reviewed. The incidence of flail chest after cardiopulmonary resuscitation was about 5.6 per 100 survivors. The groups who did and did not have flail chest after cardiopulmonary resuscitation were alike in age and in frequency and duration of the resuscitation. Stabilization of the flail chest required mechanical ventilation for 1 to 24 days (mean, 10.7). Flail chest did not significantly lengthen the hospitalization of patients who survived after cardiopulmonary resuscitation. The occurrence of flail chest after cardiopulmonary resuscitation did not seem to increase the mortality rate.

Aged↗
PubMed1992

Modern concepts in the management of flail chest.

Seven patients with varying degrees of paradoxical chest wall movement (flail chest) were managed conservatively at the University of Port Harcourt Teaching Hospital with frusemide, methylprednisolone, non administration of crystalloid fluids and limitation of fluid intake. Patients showed considerable improvement within the first 24-48 hours which was sustained throughout the period of management. All seven survived and showed no signs of respiratory distress in the resting state or while performing simple exercise. One patient however had slight to moderate chestwall deformity.

Adult↗
PubMed1997

Operative management of the flail chest.

The management of flail chest (FC) has been the subject of controversy for many years. The aim of our study was to compare results of the management of patients with FC after operative stabilization (OS) vs. nonoperative treatment (NT). One hundred and thirty-three consecutive patients with FC were assigned to treatment with OS (40 patients) and NT (93 patients). Different kinds of external extramedullar osteosynthesis were performed within 24 hour period after admission. NT includes endotracheal lung ventilation, epidural and regional anaesthesia. No difference in age, sex, shock ISS, severity pulmonary and heart contusion, extensive FC were found between both groups. Results of treatment are the following (for OS and NT respectively, p < 0.05): pneumonia 15% (6) vs. 34.4% (32); PaO2/FiO2 - 333.4 +/- 12.3 vs. 286.5 +/- 14.7; duration of lung ventilation (days) - 2.3 +/- 0.6 vs. 6.3 +/- 1.2; mortality rate - 22.5% (9) vs. 46.2% (43). Operative stabilization of chest wall should be considered when extensive FC occurs, particularly for patients with severe pulmonary and heart contusion.

Adult↗
PubMed1990

[Clinical results of selective treatment for flail chest].

A better understanding in pathophysiology of flail chest has brought an evolution to the principles of it's management. The methods of stabilization changed from surgical to pneumatic measures and now, a concept of conservative treatment is recognized. Adhering to our protocol for flail chest, which essentially limits mechanical ventilation, we have prospectively treated 36 patients since 1981. The patient were divided into two groups according to their need for mechanical ventilation. There were 16 patients (44.4%) in a group treated in conservative manner and with no mechanical ventilation (Group A). There were 20 patients (55.6%) in a group treated by mechanical ventilation (Group B). Group A had 6.2% incidence of pneumonia, 3.6 days average stay in ICU and mortality rate of 0%. Group B had 75% pneumonia, 22.5 days average in ICU and 15% mortality. Group B patients required respiratory support for 14 days average, which was not reduced by surgical stabilization. Restrictive pulmonary disturbance in group A was milder than that of group B, and this again was not affected by surgical stabilization. We conclude that 40% of flail chest are controllable without mechanical ventilation and that the result of this conservative therapy is superior to any other treatments.

Adult↗
PubMed1982

Selective management of flail chest and pulmonary contusion.

Four hundred and twenty-seven patients with severe blunt chest trauma were treated resulting in (1) flail chest, (2) pulmonary contusions, (3) pneumothorax, (4) hemothorax, or (5) multiple rib fracture. The need for endotracheal intubation and mechanical ventilation was determined selectively by standard clinical criteria. Avoidance of fluid overload and vigorous pulmonary toilet was attempted in all patients. Three hundred and twenty-eight patients were treated by nonintubation; 318 patients (96.6%) had a successful outcome, while ten required intubation. Only one patient died. The 99 patients who required intubation and mechanical ventilation had a high mortality because of associated shock and head injury; however, the total mortality for the entire group of patients was 6.5%, with only 1.4% mortality caused by pulmonary injury. The incidence of pneumonia was high (51%), but there was only a 4% incidence of tracheostomy complications. Flail chest and pulmonary contusion without flail chest occurred in 95 and 135 patients, respectively. Half of the flail chest patients were intubated, but 69.5% were intubated less than three days. Twenty per cent of the patients with pulmonary contusion required mechanical ventilation, usually for less than three days. This study demonstrates that patients with severe blunt chest trauma can be managed safely by selective intubation and mechanical, ventilation and that the incidence of complications associated with controlled mechanical ventilation can be greatly reduced.

Adolescent↗
PubMed1996

Respiratory muscle response to flail chest.

We have previously shown that flail chest in the dog causes an inspiratory inward displacement of the ribs and an increased inspiratory activity in the external intercostal muscles, and we have speculated that this increased activity is due to an increased spindle afferent activity. The present studies were designed to test this hypothesis. Twenty-nine supine anesthetized dogs were studied, and flail was produced surgically by fracturing ventrally and dorsally two to four contiguous ribs on the right side of the chest. Although flail elicited an increased inspiratory activity in the external intercostal and levator costae muscles in the disconnected segment of the rib cage, it did not alter the inspiratory activity in the diaphragm and parasternal intercostals. Expiratory activity in the triangularis sterni, internal intercostals, and transversus abdominis remained unchanged also, as did the inspiratory activity in the external intercostals on the left side of the chest. After flail, the normal inspiratory shortening of the external intercostal muscles in the disconnected segment was also reversed into an inspiratory muscle lengthening. However, when the fractured ribs were connected to the adjacent ribs so that the external intercostals were prevented from lengthening during inspiration, external intercostal and levator costae inspiratory activity was unaltered. These observations support the hypothesis that the increased external intercostal muscle activity seen in flail chest results primarily from an increased activation of the muscle spindles.

Animals↗
PubMed1983

Management of flail chest.

This paper compares the management of two groups of patients with flail chest. The 25 patients in group 1 had a flail chest without other significant injuries or shock, whereas the 57 in group 2 had a flail chest with multiple injuries, shock or both. The group 1 patients were treated with repeated multiple intercostal nerve blocks or high segmental epidural analgesia, oxygen, intensive chest physiotherapy, fluid restriction, furosemide diuretics, methylprednisolone sodium succinate and colloid infusion in an intensive care unit. In addition to these measures, the group 2 patients underwent endotracheal intubation and assisted mechanical ventilation with a volume respirator that provided continuous positive airway pressure and positive end-expiratory pressure. Of the 57 group 2 patients 36 required prolonged ventilation, eventually through a tracheostomy, because of severe head injury, pneumonia, severe facial injury, quadriplegia, pre-existing lung disease or severe sepsis. However, tracheostomy was avoided in the other 21 patients in group 2. There were no deaths in group 1, but 8 (14%) of the patients in group 2 died. These results show that avoidance of tracheostomy and ventilation in selected patients with flail chest is consistent with a low morbidity and mortality.

Adult↗
PubMed1994

Flail chest as a marker for significant injuries.

The records of 92 patients with flail chest injury treated at a Level I trauma center were analyzed retrospectively. Associated intrathoracic injuries included pulmonary contusion (46 percent) and pneumothorax or hemothorax, or both (70 percent). The incidence of great vessel, tracheobronchial and diaphragmatic injuries was no different from that of a control population with simple rib fractures. Adult respiratory distress syndrome developed in 27 percent of patients with flail chest; 69 percent of all patients required ventilation (mean duration, 22 days). Mean length of hospital stay was 24 days. The mortality rate was 33 percent. We conclude that flail chest serves as a marker of significant intrathoracic injury, highly associated with pulmonary contusion, but even more so with pneumothorax or hemothorax. Flail chest does not seem to be a marker for great vessel, tracheobronchial, or diaphragmatic injuries. The majority of patients (more than two-thirds) will require mechanical ventilation for prolonged periods. Of paramount importance is the recognition of flail chest as a marker of high kinetic energy absorption, resulting in life-threatening thoracic as well as nonthoracic injuries.

Adult↗
PubMed1995

Rib cage distortion in a canine model of flail chest.

Although blunt chest injuries frequently lead to respiratory failure, the effects of flail chest on the mechanics of breathing have not been evaluated. In the present studies, we have measured the respiratory displacements of the ribs and sternum and the electromyograms (EMG) of the parasternal and external intercostal muscles in eight supine, anesthetized, spontaneously breathing dogs before and after the third to sixth ribs on the right side of the chest were fractured both dorsally and ventrally. After flail, the fractured ribs moved inward, rather than outward, during inspiration, but their inspiratory cranial displacement remained unchanged. The inspiratory outward and caudal displacement of the sternum, the inspiratory EMG activity of the parasternal intercostals, the pattern of breathing, and the arterial blood gases were also unaltered. However, the inspiratory EMG activity recorded from the external intercostals increased consistently to 327 +/- 101% of control (p < 0.05). These observations indicate that with flail chest, the disconnected segment of the rib cage shows paradoxical motion exclusively along the lateral axis; the increased external intercostal activation may account, at least in part, for the persistent inspiratory cranial motion of the ribs. These observations also suggest that the harmful effects of blunt chest injuries are related to pulmonary contusion and pain, rather than to flail chest per se.

Animals↗
PubMed1997

Long-term follow-up of patients with operative stabilisation of a flail chest.

The outcome is reported of patients after external chest wall stabilisation for respiratory insufficiency due to a traumatic flail chest. Since 1990, all patients with a flail chest causing respiratory insufficiency despite peridural analgesia and without further reason for prolonged mechanical ventilation underwent osteosynthesis of the chest wall using the AO-technique with 3.5 mm thick reconstruction plates, and were prospectively followed-up by use of clinical and radiological evaluation. 23 patients underwent external chest wall fixation between 1990 and 1996 and were followed for a mean time of 28 months. 2 patients died after the operation, giving a 30-day-survival rate of 91.3% 21 patients survived and were extubated and transferred to the ward after a mean time interval of 3.9 and 7.8 days, respectively. 95% of the survivors revealed a 100% working capacity at assessment and 86% returned to preoperative sports activities without complaining of chest wall or shoulder girdle pain or dysfunction. External chest wall fixation appears to be an attractive alternative to prolonged intubation and mechanical ventilation for selected patients with flail-chest respiratory insufficiency despite peridural analgesia, providing they do not require prolonged intubation for other reasons.

Adult↗
PubMed1981

Stabilization of flail chest by compression osteosynthesis--experimental and clinical results.

It has been demonstrated that the impaired ventilatory parameters can be normalized after early stabilization of flail chest. Most methods for operative fixation, however, have given disappointing results and only plate fixation procedures have been effective. The experimental results of osteosynthesis with dynamic compression plates are presented and demonstrate the superiority of compression osteosynthesis in rib fractures. Compression osteosynthesis resulted in a primary fracture healing with stable fragments after 14 days, whereas conventional plate fixation techniques required a much longer time and showed secondary fracture healing. The benefits of compression osteosynthesis could also be demonstrated in 10 patients with traumatic flail chest. Osteosynthesis resulted in marked pain relief, immediate stabilization of the chest wall, and a shorter time of intubation. Not all fractured ribs need stabilization, dorsal fractures are well fixed by the strong erector muscles, and in the lateral position only ribs III to VII need to be considered. Reasonable stabilization may be achieved with fixation of every second rib. In patients with bilateral rib serial fractures subcutaneous implantation of one or 2 rib struts is recommended--good results were obtained in 12 patients. The indication for operative stabilization of flail chest should be restricted to: 1. Patients with severe ventilatory restriction due to chest wall paradox alone. 2. Flail chest combined with intra-thoracic lesions which require thoracotomy. 3. Flail chest combined with lesions which require a prone position for surgical exploration. 4. Respiratory distress patients when the unstable chest wall interferes with mechanical ventilation or with underlying organs.

Adolescent↗