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Tue Jul 7 20:00:36 BST 2009

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I think it is still a procedure looking for a pathology!

Tim
> Dear Dr. Hardcastle,
>
> Your experience with blunt chest injuries is impressive. May I ask how
> many
> of these flails were surgically repaired with metal plates, etc.?
>
> Thanks.
>
> Jose Luis J. Danguilan, MD
>
>
> On Tue, Jul 7, 2009 at 2:46 PM, Dr Timothy Hardcastle <
> dr.tchardcastle at absamail.co.za> wrote:
>
>> 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
>> >
>> > --
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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

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Non invasive Ventilation with Flail Chest