Flail chests

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From: KMATTOX at aol.com
> we each perceive a different visual image of just what is meant by the words, "Flail Chest."

 

--> I think the confusion is between "flail chest" (the condition) and "flail segment" (the chest wall in that condition).

 

I have a theory as to why this might be happening, at least in this country: Most people who speak about these terms and use these terms are NOT the people who deal with the condition. They are used in ATLS here and many people who are trained on these courses are junior doctors who then do not go on to have careers involving this sort of trauma...

 

I am not complaining that they are taught ATLS - I am merely proposing an idea to explain why people hear the term and then no more...

 

BTW, in my experience, many flail SEGMENTS (the loose chest wall portion) are not evident and do not move paradoxically. We are often finding these only on CT. Even then, when we have proof that there is a loose chest wall segment with pictures of it, we are still unable to see it on the patient! And, no, before anyone "saves" me, we're not looking for them on ventilated patients... ;-)

 

Even in spontaneous respiration, before the patient is ventilated, it might well require more negative thoracic pressure to move the segment paradoxically that the patient, in his condition and pain, is able to manufacture... And, at other times, it is posterior and thus the sign is conteracted by gravity somewhat and/or simply not in line of sight. Or it may be rendered less visible by being covered  with more layers of fat than allow it to be visible...

 

When teaching this concept, on ATLS and other opportunities, I make sure to explain carefully and ensure understanding of the importance of anticipating the flail CHEST and lung pathology, even if it is not yet evident (I mostly teach EPs & pre-hospital). I highlight the flail SEGMENT as but a sign (a painful one) of the potential pathology UNDERLYING it, or about to.

 

One way I do this is by telling people something like "if the mechanism makes you LOOK for a flail SEGMENT, then ASSUME there is a flail CHEST, until proven otherwise, even if the skin & bones move apparently normally".

 

We then go on to discuss NOT over-hydrating, the use of ventilation, oxygenation, monitoring!, analgesia, analgesia and did I mention analgesia...
 		 	   		  

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