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Flail chest

Discussion in 'First Aid Station' started by Sharps, Mar 25, 2012.

  1. Sharps

    Sharps Loaded Pockets

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    So for all the other Medics/ER Docs out there, I've seen all kinds of posts on here about GSW, massive hemorrhage, and penetrating chest trauma. I don't think I've seen anything however about treating flail chest in the field and I'm curious about your thoughts on the subject.

    Some background: I've been a first responder and then an EMT-1 for about 3 years for a rural EMS service. I've seen some of everything but for some reason never run across a flail chest.
     
  2. VinnyP
    • In Omnia Paratus

    VinnyP Loaded Pockets

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    In a conscious patient without pain relief they almost certainly won't tolerate any kind of field treatment. So first treat the pain then the usual support the flail with something soft.
     
  3. Sharps

    Sharps Loaded Pockets

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    I think positioning on the side with the flail segment combined with towel rolls secured with tape or something was what we were taught? Unfortunately EMT-1's EMT-B to most of you) aren't allowed to give pain meds. Side note: Do you have to worry about decreasing respiratory drive when giving pain meds (I'm assuming some kind of opiate) for this since the pt. is already having difficulty breathing?
     
  4. AAROSOL

    AAROSOL Loaded Pockets

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    there isnt much to do for flail chest in the field. some literature supports CPAP for pneumatic stabilization from the inside. but pretty much, just get them quickly to the ED. the underlying pulmonary contusion and the other traumatic injuries that most likely have occurred to even cause these multiple ribs fractures are more worrisome and should be stabilized in a hospital setting.
     
  5. WildEMT

    WildEMT Loaded Pockets

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    Ditto all that. Position of comfort on injured side, large padding to cushion the injured area... rapid evac.

    It might be a good thing that you never saw a flail chest... ?
     
  6. WildEMT

    WildEMT Loaded Pockets

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    Double-post. Getting click happy in a slow-to-respond forum.
     
  7. Sharps

    Sharps Loaded Pockets

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    Oh I'm not complaining about having avoided it so far. The padding is also supposed to provide support for the injured segment as well correct?

    I think the most impressive (read horrible) trauma I've seen was a 4 wheeler rollover. That poor guy had: pelvic fx, bi-lat femur fx, clavical fx, some abdominal injury I can't remember but I'm sure wasn't good, and completely blew out his T-12 and L-1 vertebra. He actually used the words "It feels like my feet are on fire" I know he lived but I'm not sure how he recovered....
     
  8. WildEMT

    WildEMT Loaded Pockets

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    The padding, as far as I understand, is meant to prevent any further knocks or dings to the injured area. As was noted before, flails are extremely painful. So, it is just to stop it from getting hit. Doesn't do anything seriously medical for the injury (if my memory serves correctly).

    Saw a big hydrostatic lawn tractor flipped on a gal once... pinned her head in a ditch. She recovered with very, very minor cognitive damage. It's amazing what those folks in a good trauma center can do.
     
  9. AAROSOL

    AAROSOL Loaded Pockets

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    I cant remember which is the most horrible trauma I've seen but it has to be either the pizza delivery guy who got half his face shot off by a shotgun, a motocyclist with his leg torn off (with about 10 other broken bones), a guy who tried to steel the copper wires from the train station but got electrocuted with both his arms severely burned (which were later cut off) with a hole the size of a basketball in his abdomen for an exit wound, or a guy that had 17 bullet holes in his body, 4 fractured bones from the bullets, one to his head (didnt hit anything vital apparently) , and one which was through the shaft of his, well you know. after alerting him of that last fact, he promptly replied, "they shot my d***? just let me die, kill me now." it was kind of hard not to laugh. kid survived.
     
  10. tower
    • In Omnia Paratus

    tower Loaded Pockets

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    If your in the wild and don't have much in the way of supplies, hemi-circumferential duct tape can work miracles.
     
  11. AlteredMentalStatus

    AlteredMentalStatus Loaded Pockets

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    I do believe the padding in pre-hospital treatment for a flail chest is done very much for the patient's comfort. You technically could stabilize a segment with just tape or your palm but that would suck; throw in some cushioning material (towels, pillow, etc.) and the situation sucks a bit less for the patient's exhalations.

    Flail chests are always interesting to see. Can't do much in field for them though.
     
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  12. tower
    • In Omnia Paratus

    tower Loaded Pockets

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    But if you use tape without padding, you do more to limit the reciprocal motion of the chest wall.
     
  13. Sharps

    Sharps Loaded Pockets

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    I can't think of many things duct tape or 3 inch dermapore tape can't fix haha. Get a group of medics together and eventually they start telling war stories lol.
     
  14. Janvier

    Janvier Loaded Pockets

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    As some have mentioned, tape. The problem with flail chest (also causing the pain) is that the flail segment is moving in the opposite direction of the rest of the chest wall, so the broken bone bits are moving and grinding and doing all manner of unpleasant things. If you can reduce that as much as possible, you reduce the pain and can consequently ease the breathing difficulty. Tape can help encourage the flail segment to move in sync with the rest of the chest wall, with varying success. Rapid transport...
     
  15. Joelski

    Joelski Loaded Pockets

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    Flail segments frequently go undetected in the field because of chest wall muscle spasm and splinted/shallow respiration. For initial treatment a simply allow the patient to splint their chest with position of comfort; that splinting you note may be a dead giveaway of a flail segment! Never wrap all the way around the chest with tape or cravats. A soft, bulky dressing like a multi-trauma gauze pack and semi-circumferential tape will provide a good shock absorber so the patient is able to then splint the segment with his/her arm.

    I'd be very cautious with CPAP, as the force associated with multiple rib fractures is certainly enough to cause a pneumothorax as well. CPAP would be great for pulmonary contusion, but will accelerate a tension pneumo. Lung sounds aren't a great indicator because the patient will be in too much pain to breathe deeply. Finally, reassess the patient for changes throughout your contact with him/her and compare things like vitals, pain level etc.. to the baseline you established in your initial assessment. That information will be a big help to the trauma team when you arrive at the ED!
     
  16. joseywales44

    joseywales44 Loaded Pockets

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    OK, they taught us to use "a 2 lb. sandbag '" and tape it firmly but not tightly to the chest to stabilize the flail segment. Just so happens that a standard IV bag is the perfect approximation of said 2 lb. sandbag and since that rather than a sandbag IS normally carried on the truck, that's what I used.
     
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  17. jagleaso

    jagleaso Empty Pockets

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    There have been a couple studies (I think Turkey and Japan) that have shown decreased mortality with use of CPAP in flail chest patients without complete respiratory compromise while in the ICU. Unfortunately it didn't decrease total length of hospitalization which is all I care about. With that being said I haven't placed a flail chest on CPAP yet (I dont have room for it in my edc). YMMV.
     
  18. Joelski

    Joelski Loaded Pockets

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    Yeah, they're getting smaller but not quite there yet!
     
  19. Joelski

    Joelski Loaded Pockets

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    Wow, that was a long time ago! Think about it this way: would you want 2 lbs of anything sitting on, over, or even bridging a free floating section of your chest wall? Throw is a couple potholes for effect and you see the reason why the method of stabilization has changed to a bulky dressing (Comfy pillow, pocket lint for EDCers :D). I'm surprised that hasn't brought up in a refresher class. That changed 20 years ago!
     
  20. medic2807

    medic2807 Loaded Pockets

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    Just sedate, paralyze and intubate them. If you have CPAP, chances are you can RSI someone. I like fentanyl drips at about 250-500 mcg./hr. for these guys. The patient does, too. In the field? Well, I've done pillows and IV bags, but really, it isn't gonna help.

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