Flail chests

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We too have started to do ribs fixations on some of our more complex 
chest injuries during the course of which I have done rather extensive 
background search. Dr. Maddox is absolutely right in that part of the 
problem here is that there is no true definition of flail chest. Once in
 a while you find it defined as two or more ribs broken into or more 
places creating the classic flail segment. More often however what you 
find is that "flail chest" means lots of broken ribs. The most recent edition of ATLS defines it as "a segment of the chest wall which does not have only continuity with the rest of the thoracic cage". It then goes on to say "the major difficulty in flail chest stems from the injury to the underlying lung".

Even the 
term itself is fairly recent. The first mention of it I can find in 
literature is a 1945 article in JAMA ( "immediate care of the wounded 
thorax" Samson et al 27 October 1945 page 606) describing casualty care 
in the second world war. The term is in quotation marks the first time 
it's used and I suspect was therefore a newly coined term. If anyone
 else is aware of an earlier use of the term please let me know. 
Interestingly even at this early time the underlying lung injury was 
recognized as being the major defect ("traumatic wet lung" )

In terms of the flail segment itself, if I am not mistaken, somewhere in the 80s or 90s if somebody did a study where they surgically created flailed segments in dogs by cutting rather than breaking ribs. When they studied the pulmonary functions in these dogs they found only about 10% decrease in vital capacity. I have been unable to locate the study in my meanderings through literature, again if anybody has a copy of it I'd appreciate it. Or maybe it doesn't actually exist and I've just been mistaken all these years. One thing that nobody seems to take into account when discussing this however is the patient with COPD or severely compromised pulmonary function where indeed this relatively small decrease in function may be enough to tip them over the edge.

The eight patients we've done so far have had varying indications including herniated lung and severe (really severe!) chest wall deformity along with pain control and difficulty weaning from the vent. All have done quite well, unfortunately this is all anecdotal since I don't have good level I data to demonstrate it. Nor do I have any long-term follow-up. Despite what the commercial organizations are pushing as decreased ICU stay and decreased vent time I strongly suspect in the end what we are going to find is a significant improvement in long-term morbidity in the most severely injured and some recent studies have at least suggested that there is a significant increase in return to work in patients who undergo rib fixation. there are groups in Europe who (based on one paper with a small sample) are choosing to perform repairs on patients over 50 with three or more fractures. Based on what I've seen so far I'm not ready to make this recommendation and
 I suspect the final discriminator is going to turn out to be something along the lines of degree of chest wall deformity.

R. Wigle MD FACS
Assistant Professor Surgery/  Trauma, Critical Care
LSU Shreveport
Shreveport Louisiana

--- On Thu, 8/19/10, Gross, Ronald <Ronald.Gross at baystatehealth.org> wrote:

From: Gross, Ronald <Ronald.Gross at baystatehealth.org>
Subject: RE: Flail chests
To: "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
Date: Thursday, August 19, 2010, 6:44 AM

Wait - the flail segment has absolutely noting to do with the respiratory failure.  Respiratory failure leading to intubation results from the pulmonary contusion suffered at the time of injury, and the rib fractures are merely indicative of the force vectors and energy transfer that caused the pulmonary contusion.  In someone with a pulmonary contusion and flail segments, inadequate control of the pain resulting from the rib fractures can push someone over the edge re: intubation as the atelectasis worsens the already compromised pulmonary function.

As to the "new" concept of fib fixation/repair in those with flail segments or multiple fractures and/or severely displaced ribs, this is not new - just ask Don Trunkey!  Many of us are now revisiting the procedure, as some preliminary work has shown dramatic reductions in the need for ventilatory support (or the avoidance of it altogether), decreased ICU and hospital LOS, earlier return to work and/or ADL, and markedly improved PFT's at 6 months and one year.  There is some good data that I have recently seen (that is as yet unpublished) from MUSC that has prompted them to routinely repair rib fractures in patients that we would not normally have done in the past.  I, for one, plan to look at their protocols and be much more aggressive in my approach to these fractures, as I have already "signed on" to the concept and approach, and have brought the rib fixation equipment into our institution!

Best wishes,
Ron

-----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 7:39 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: Flail chests

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
>> --
>> trauma-list :  TRAUMA.ORG
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>>
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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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> http://www.trauma.org/index.php?/community/
>



-- 
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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