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Wed Aug 18 12:58:55 BST 2010

I think it's clear that Dr. Mattox is referring to the morbid consequences of flail chest, and not the primary injury.  It makes intuitive sense that hyper-resuscitation is hard on contused lungs, and we've certainly seen as much in our patients.

It'd be interesting to quantify, though.  Are there any studies to support the assertion?

Pret Bjorn, RN
Bangor, ME USA

PS: The assertion that " aggressive field resuscitation allows more of these patients to survive to admission" is not only unsubstantiated; it runs contrary to a growing heap of published data.  It's a dated and dangerous notion.

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Stephen Richey
Sent: Wednesday, August 18, 2010 2:49 AM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: Flail chests

Dr. Mattox,
Can I ask you to elaborate how excessive fluid resuscitation and a
flail chest are tied to together?  I know my mechanisms of injury
pretty well since I do injury prevention research but either you are
picking up on something I am missing or you are seeing a false
correlation.

Could it be that patients with flail chest, which in most trauma
patients indicates a severe blow to the chest and/or a very
non-compliant chest wall  (and the resultant increase in severity of
the trauma to internal organs and vascular structures associated with
either of those) that the aggressive field resuscitation allows more
of these patients to survive to admission where many of them suffer
the complications and negative implications of that resuscitation well
documented by yourself and your colleagues?  In other words, the fluid
resuscitation simply shifts the mortality from the prehospital to the
in-hospital phase (immediate versus delayed in the classic tri-modal
distribution). Like I said, maybe I am missing something or
misunderstanding what you are trying to get at.  That said, I do agree
that the section needs to be revised.

Dr. Gross, if you don't mind, I would like to hear more about your
proposed study off-list.

Steve

>> In the absence of fluid overload in the ambulance or the EC, "flail"
>> segments of multiple rib fractures are almost NEVER seen.     Flail Chest should be considered to be an iatrogenic complication of the  protocols which start 2 large bore IVs and flood the patient with  fluid.       Yes, I do believe that ATLS needs its  fluid resuscitation section revised.
>>
>> k
>>
>>
>> In a message dated 8/17/2010 11:08:37 A.M. Central Daylight Time,
>> Ronald.Gross at baystatehealth.org writes:
>>
>> Funny  timing here, Mark!  I have been struggling to pull a study
>> together,
>> and  was hoping to work with the guys on the west coast to get it going
>> since they  apparently already have a protocol in search of a funding
>> source.
>> Unfortunately, it looks like they want to make a go of it on their own.
>> Coincidentally, the Boston group and I talked about this in the recent
>> past,
>> and at the same time we just hired a new partner who just happens to have
>> really good results that they have gathered at his previous  shop.
>>
>> Bottom line - stay tuned, 'cause I am going to reach out to y'all  very
>> shortly to hopefully move this almost dead study forward into the light
>> again!
>>
>> While I have your attention - has anything ever come of that  other issue
>> you and I had discussed several months ago?  I hadn't heard  any news, and
>> so
>> I assumed that it was just a lot of nothing......at least I  hope so!  Let
>> me know, if you have the time.
>>
>> Best  wishes,
>> Ron
>>

-- 
Stephen Richey, CRT

"A man's moral worth is established only at the point where he is
ready to give up his life in defense of his convictions."- Henning von
Tresckow
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Flail chests