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Wed Jul 8 15:23:09 BST 2009

Hmmm ... significantly underpowered and the mortality difference could 
easily be a chance finding with small numbers. All you can say from this 
is "maybe ..." ie hypothesis generation, and go on to design the proper 
large study.

Importantly, as Dr Hardcastle indicates, it is crucial to distinguish 
whether the problem is PAIN from broken ribs  [needs good analgesia, 
maybe short term NIV] or HYPOXAEMIA from lung contusion [needs 
intubation earlier rather than later, and NIV could be hypothesized to 
worsen outcomes by extrapolation from other conditions such as pneumonia]

Ian Seppelt, Sydney

Zaffer Qasim wrote:
> Tim
>
> This attached article may be of interest to you.
>
> Zaf
>  
> Dr. Zaffer Qasim MBBS MRCS MCEM
> Specialty Registrar in Emergency Medicine and Critical Care
> Manchester, United Kingdom
>
>
>
>   
>> Tim,
>>
>> Do you know of any data published regarding NIPPV and flail chest?
>> Impressive anecdotal experience. Thanks for sharing.
>>
>> Keith
>> On Tue, Jul 7, 2009 at 2:46 AM, 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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>>>       
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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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> trauma-list : TRAUMA.ORG
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