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Thu Aug 19 00:38:59 BST 2010

Ah...I see what you are getting at now Dr. Mattox.  It is simply a
matter of how I was taught: that flail chest was the chest wall injury
and not the underlying pulmonary injury and resultant complications.
.

My only concern with the use of "flail chest" in this situation (to
describe the entire clinical syndrome you are talking about)  is that
it describes a scenario that is more or less two separate (although
intertwined) problems: namely a flail segment with contused lung that
leads to respiratory failure.  Practically you could have the latter
without the former (and need the same treatment to avoid worsening the
condition) and theoretically could have (at least in the patient with
brittle ribs, etc) have the former without the latter.

Forgive me if that is a little rambling...

On Wed, Aug 18, 2010 at 7:26 PM,  <KMATTOX at aol.com> wrote:
> It is obvious to me that the works of the late Kent Trinkle, first of
> Louisville, Ky, and later of San Antonio, Texas are beginning to be  forgotten;
>
> It is also apparent that we each perceive a different visual image of just
> what is meant by the words, "Flail Chest."     For decades  flail chest
> referred to a syndrome of pulmonary insufficiency asssociated with a  contused
> lung from blunt chest wall trauma, with multiple rib fractures seen in
> different locations anterior and posterior or parasternally, and manifest  by
> an external paradoxical movement of the flail segment, resulting in a
> rocking motion of the chest wall with inspiration and  expiration.
>
> Most often no abnormality was seen when the patient first came into the
> emergency room, and would have a relatively normal blood gas, but would have
> hypoxemia later often requiring intubation.
>
> Patients who had rib fractures in multiple locations and were not hypoxemic
>  were not said to have a "flail chest".     In those days ,  flail chest
> was treated by fixation of the chest wall, often by traction applied  to a set
> of pins placed beneath the pectoral muscles or the sternum, in order to
> stop the paradoxical movement, with no attention to the progressively water
> filled lung underneath.
>
> With Kent Trinkles work, we all learned and stopped over hydrating the
> patients.   He should be credited with the whole movement of fluid  restriction
> in trauma patients.       Then 18  years later came along the sporatic and
> regionally popular operative fixation of  multiple rib fracture segments and
> there was a whole new interest in flail  chest.      That technique is
> still being questioned as  to its indications and contraindications.     AND it
> has  resulted in a whole generation of people creating a new meaning for the
> terms  flail chest.
>
> Just as there is a whole generation of radiologist and vascular surgeons
> that are creating a whole new definition of the word  "dissection."
>
>   We need a new lexicon .
>
> k
> a
>
> In a message dated 8/18/2010 8:28:02 A.M. Central Daylight Time,
> stephen.richey at gmail.com writes:
>
> Pret,
> Then I would think it would have made more sense for him  to make the
> statement that there is a correlation between lung injury  and
> excessively aggressive fluid resuscitation and not specifically  flail
> chest.  Maybe once he gets back with us, he will be able to  clarify
> just what he was speaking towards.  Like I said, I was  probably
> missing something especially since my reply was made on little  sleep
> and a lot of caffeine.
>
> Of course, nothing is "intuitive"  (although I do see what you are
> driving at and tend to agree with you based  on what data I have seen)
> since it seemed intuitive at one time to restore  patients who were
> hypotensive due to trauma to normal blood  pressures.  That is the risk
> inherent in relying upon intuition in  trauma.  Personally, I too would
> love to see it quantified.
>
> On  Wed, Aug 18, 2010 at 7:58 AM, Bjorn, Pret <pbjorn at emh.org>  wrote:
>> 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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>
>
>
> --
> 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
> --
> trauma-list : TRAUMA.ORG
> To  change your settings or unsubscribe  visit:
> http://www.trauma.org/index.php?/community/
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> trauma-list : TRAUMA.ORG
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>

-- 
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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