Non invasive Ventilation with Flail Chest

• Previous message: Non invasive Ventilation with Flail Chest
• Next message: Non invasive Ventilation with Flail Chest
• Messages sorted by: [ date ] [ thread ] [ subject ] [ author ]

Hi Christine

No "protocol" as such, just extensive experience (>300 major blunt chest
trauma in the last 5 years) and therefore can give you some guidance that
may assist you. (Maybe will help you to derive your own protocol). The
reason I don't advocate a "protocol" here is that each patient is very
individual in how they cooperate / cope with the support offered, so a
general apporach is more relevant.

Firstly: Flail chest is mainly a cause of pain, while underlying contusion
is the cause of shunt and hypoxia, so analgesia is the first step; either
epidural, or intercostal blocks,or combination opioid / non-opioid IV in
suitable doses - PCA useful if patient able to cooperate. Aim for Ramsay
2-3 sedation level. If intercostal drain in-situ could even use
intra-pleural catheter with bupivacaine.

Secondly assess the extent of lung contusion - the worse the contusion the
less likely non-invasive ventilation will work; rather intubate early and
wean to extubate around day 5, then continue with non-invasive.

If primarily rib fractures with limited severity of contusion, then early
non-invasive ventilatory support is most appropriate: I start with a
full-face mask, with portal for a naso-gastric tube to decompress the
stomach - they all swallow air; use between 8 - 10 mmHg CPAP with a
combination of additional pressure support adjusted to achieve internal
splinting (minimal residual flail) or Vt of 6 - 8 ml/kg, whichever comes
first. Aim for sats >92% or PaO2 of over 8kPa (68mmHg) as minimum. Titrate
both CPAP and the PSV/ASB as required.

Aim for a spontaneous resp rate less than 30 - more than this and they
will tire - this group will require intubation and ventilation.

Regular checks for developing VAP are essential. Screening wth ProCal is
useful.
Antibiotics are best avoided unless true infection is diagnosed.
Prophylactic AB are not required for lung contusion.

Hope this helps
Tim
Dr T C Hardcastle
M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
Principal Specialist Trauma Surgeon /
Honorary Lecturer University of KwaZulu-Natal Dept Surgery
Deputy Director - IALCH Trauma Service
Durban - South Africa

> Has anyone have any protocols for managing traumatic chest injuries such
> as a flail chest with non invasive ventilation?
> --
>
> Chris Wilson
>
> Lecturer in Nursing
>
> Flinders University
>
> 82013354
>
> 0414253393
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/

• Previous message: Non invasive Ventilation with Flail Chest
• Next message: Non invasive Ventilation with Flail Chest
• Messages sorted by: [ date ] [ thread ] [ subject ] [ author ]