greentextmedic:

Trauma Time with Greenie - Flail Chest, Part III

Stabilizing a flail chest is tricky —you must depress the segment to the anatomically correct alignment and reduce instability, all without interfering with respirations. However, there are two quick fixes for this —the first, is obviously hold pressure manually. The second, is to stack linen sheets over the segment and let gravity hold it in place. You will be wasting valuable time trying to intricately dress this sort of wound with gauze and 2” tape or wrapping an Ace wrap around the entire chest.

Always complete your trauma assessment —do not stop after stabilizing or performing interventions on the flail chest. If the mechanism of injury was powerful enough to cause a flail chest, there is a good chance that there will be other injuries. It is easy to get sucked into this type of major trauma —it’s big and it’s obvious, but it’s always the little things that you miss that will endanger the patient. Even if your assessment reveals no other injuries, maintain C-spine —the flail chest qualifies as a distracting injury and can mask the presentation of other injuries.

Other major trauma protocols like intravenous access and fluid resuscitation still apply if they are within your scope of practice. Preferably, two large-bore INTs in the bilateral ACs are the best route for rapid intervention. Consider intraosseous access if you have a decreased LOC, rapidly deteriorating respiratory drive and are unable to establish a patent IV. Be guarded with your fluid bolus and do not attempt to raise the pressure higher than 90 systolic or until you return peripheral pulses.

A patient with this injury warrants immediate transport to the nearest appropriate trauma-receiving hospital. Do not be concerned about missing a few steps along the way so long as you cover the basics. It is nearly impossible to perform all the interventions I’ve listed here in the time it takes from initial-patient-contact to transfer-of-care at the hospital —even with the help of multiple pre-hospital providers. Do what you can to keep the patient alive long enough to make it to the operating room.

That’s all any of us can hope for with a patient like this.

greentextmedic:

Trauma Time with Greenie - Flail Chest, Part II

A flail chest is way up there on the list of life-threatening injuries. In the pre-hospital setting, it should be the first injury you address during your initial trauma assessment after stabilizing C-spine, assessing LOC and performing your ABC’s. 

Your first hands-on assessment of the flail chest should be bilateral lung sounds and heart tones. Labored breathing, but clear lung sounds is to be expected early on in the disease process. Heart tones should be clear and crisp. Having a good baseline will help you determine the extent of internal damage and the rate of bleeding or air leakage inside the chest. Should the lung sounds be diminished or absent, look for evidence of tracheal deviation or tugging. This would suggest a tension pneumothorax —be prepared to decompress a flail chest if it is within your scope of practice.

Patients with flail chests fatigue very quickly. The work of breathing they must do has been doubled with the loss of effective chest wall movement on one side. They should be given supplemental high-flow O2 regardless of presenting blood O2 saturation. Be prepared for the patient’s respiratory rate to plummet as they decompensate —you will have to ventilate the patient with a BVM if they become agonal or apneic. Should the patient go unconscious and unresponsive, consider advanced airways or intubation if it is within your scope of practice.

Any three symptoms of Beck’s Triad could suggest cardiac tamponade. Assess for distended jugular veins, muffled heart tones and hypotension. If it is within your scope of practice, place the patient on the cardiac monitor. Obtain a 3-lead to determine sinus rhythm and accurate pulse should peripheral pulses be absent. Cardiac alternans and low-voltage readings on the EKG could also indicate cardiac tamponade, but do not delay on scene with obtaining a 12-lead to confirm cardiac effusion. Additionally, there is no longer a pre-hospital protocol for pericardiocentesis.