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FLAIL CHEST

Flail chest is

traditionally described as the paradoxical movement of a segment of chest wall


caused by fractures of 3 or more ribs anteriorly and posteriorly within each rib.
Variations include posterior flail segments, anterior flail segments, and flail
including the sternum with ribs on both sides of the thoracic cage fractured.
Flail chest is foremost a clinical finding and observation that is often
accompanied by physiologic derangements, which are sometimes
globally lumped into the diagnosis. The lumping of signs and symptoms
has resulted in confusion regarding both the treatment strategies and
the overall importance of the clinical finding.
Mechanically, flail chest generally requires a significant force diffused
over a large area (ie, the thorax) to create multiple anterior and
posterior rib fractures. If the structural components (ie, the ribs) are
weakened for any reason (eg, osteoporosis), then much lower force
may be required. The actual motion of the flail segment is usually limited
by the surrounding structural components, the intercostals, and the
surrounding musculature. This mechanical limitation of motion affects the
actual size of the changes in thoracic volume and patient-generated tidal
volume. Underlying pulmonary or cardiac disease determines the
physiologic perturbations to respiration caused by the flail segment.
Even more important is the amount of injury to the underlying structures, specifically the lungs and heart.
Respiratory insufficiency in flail chest is much more likely to be a result of the underlying severity of pulmonary
contusion and ventilation perfusion mismatch than the actual structural defect to the chest wall. Thus, the adept
surgeon usually looks past the structural deformity and determines the physiologic compromise caused by the
pain of the rib fractures, the tidal volume changes, and the underlying pulmonary and cardiac injury.
Chest wall injury is a extremely common following blunt trauma. It varies in severity from minor bruising or an
isolated rib fracture to servere crush injuries of both hemithoraces leading to respiratory compromise.
While many chest injuries will require no specific therapy, they may be indicators of more significant underlying
trauma. Multiple rib fractures will often be associated with an underlying pulmonary contusion, which may not be
immediately apparent on an initial chest X-ray. Fractures of the lower ribs may be associated with
diaphragmatic tears and spleen or liver injuries. Injuries to upper ribs are less commonly associated with injuries
to adjacent great vessels. This is especially true of a first rib fracture, which requires a significant amount of
force to break and indicates a major energy transfer. A fracture of the first rib should prompt a careful search for
other injuries. Note also that the rib cage and sternum provide a significant amount of stability to the thoracic
spine. Severe disruption of this 'fourth column' may convert what would otherwise be a stable thoracic spine
fracture into an unstable one.
Flail Chest
A flail chest occurs when a segment of the thoracic cage is separated from the rest of the chest wall. This is
usually defined as at least two fractures per rib (producing a free segment), in at least two ribs. A segment of the
chest wall that is flail is unable to contribute to lung expansion. Large flail segments will involve a much greater
proportion of the chest wall and may extend bilaterally or involve the sternum. In these cases the disruption of
normal pulmonary mechanics may be large enough to require mechanical ventilation.
The main significance of a flail chest however is that it indicates the presence of an underlying pulmonary
contusion. In most cases it is the severity and extent of the lung injury that determines the clinical course and
requirement for mechanical ventilation. Thus the management of flail chest consists of standard management of
the rib fractures and of the pulmonay contusions underneath.
Diagnosis
Most significant chest wall injuries will be identified by physical examination. Bruising, grazes or seat-belt signs
are visible on inspection, and palpation may reveal the crepitus associated with broken ribs. Awake patients will
complain of pain on palpation of the chest wall or on inspiration.
A flail chest is identified as paradoxical movement of a segment of the chest wall - ie indrawing on inspiration
and moving outwards on expiration. This is often better appreciated by palpation than by inspection.

Chest X-ray
The antero-posterior chest radiograph will identify most significant chest wall injuries, but will not identify all rib
fractures. Lateral or anterior rib fractures will often be missed on the initial plain film. However, since the
management of rib fractures is determined by their clinical significance rather than by their number or position,
dedicated rib views are never indicated.
For adult blunt trauma patients, a haemothorax, pneumothorax or pulmonary contusion seen on chest X-ray will
almost always be associated with a rib fractures, whether or not identified clinically or by X-ray. In paediatric
patients the ribs are more pliable and less likely to fracture, although there will still be significant contusion of
chest wall structures.
PNEUMOTHORAX
Primary spontaneous
A primary spontaneous pneumothorax is one which occurs in a patient with no known underlying lung disease.
Tall and thin people are more likely to develop a primary spontaneous pneumothorax.
Secondary spontaneous
When the underlying lung is abnormal, a pneumothorax is referred to as secondary spontaneous. There are
many pulmonary diseases which predispose to pneumothorax including:

o
o
o
o
o
o
o
o

o
o
o

o
o

cystic lung disease


bullae, blebs
emphysema, asthma
pneumocystis jiroveci pneumonia (PJP)
honeycombing: end stage interstitial lung disease
lymphangiomyomatosis (LAM)
Langerhans cell histiocytosis (LCH)
due to apical lung changes from ankylosing spondylitis 1
cystic fibrosis
parenchymal necrosis
lung abscess, necrotic pneumonia, septic emboli, fungal disease,tuberculosis
cavitating neoplasm, metastatic osteogenic sarcoma
radiation necrosis
other
catamenial pneumothorax 2,4: recurrent spontaneous pneumothorax during menstruation,
associated with endometriosis of pleura
rarely pleuroparenchymal fibroelastosis 9

Iatrogenic/traumatic
Iatrogenic/traumatic causes include 1-4:

o
o
o

o
o

iatrogenic:
percutaneous biopsy
barotrama, ventilator
radiofrequency (RF) ablation of lung mass
trauma:
pulmonary laceration
tracheobronchial rupture

acupuncture

Signs and symptoms

A primary spontaneous pneumothorax (PSP) tends to occur in a young adult without underlying lung problems,
and usually causes limited symptoms. Chest pain and sometimes mild breathlessness are the usual
predominant presenting features.[1][2] People who are affected by PSPs are often unaware of potential danger
and may wait several days before seeking medical attention.[3] PSPs more commonly occur during changes
in atmospheric pressure, explaining to some extent why episodes of pneumothorax may happen in clusters.[2] It
is rare for PSPs to cause tension pneumothoraces.[1]

Secondary spontaneous pneumothoraces (SSPs), by definition, occur in individuals with significant underlying
lung disease. Symptoms in SSPs tend to be more severe than in PSPs, as the unaffected lungs are generally
unable to replace the loss of function in the affected lungs. Hypoxemia (decreased blood-oxygen levels) is
usually present and may be observed as cyanosis (blue discoloration of the lips and
skin).Hypercapnia (accumulation of carbon dioxide in the blood) is sometimes encountered; this may
causeconfusion and - if very severe - may result in comas. The sudden onset of breathlessness in someone
withchronic obstructive pulmonary disease (COPD), cystic fibrosis, or other serious lung diseases should
therefore prompt investigations to identify the possibility of a pneumothorax.[1][3]

Traumatic pneumothorax most commonly occurs when the chest wall is pierced, such as when a stab
wound or gunshot wound allows air to enter the pleural space, or because some other mechanical injury to the
lung compromises the integrity of the involved structures. Traumatic pneumothoraces have been found to occur
in up to half of all cases of chest trauma, with only rib fractures being more common in this group. The
pneumothorax can be occult (not readily apparent) in half of these cases, but may enlarge - particularly
if mechanical ventilation is required.[2] They are also encountered in patients already receiving mechanical
ventilation for some other reason.[2]

Upon physical examination, breath sounds (heard with a stethoscope) may be diminished on the affected side,
partly because air in the pleural space dampens the transmission of sound. Measures of the conduction of vocal
vibrations to the surface of the chest may be altered. Percussionof the chest may be perceived as
hyperresonant (like a booming drum), and vocal resonance and tactile fremitus can both be noticeably
decreased. Importantly, the volume of the pneumothorax can show limited correlation with the intensity of the
symptoms experienced by the victim,[3] and physical signs may not be apparent if the pneumothorax is relatively
small.[2][3]

Tension pneumothorax
Although multiple definitions exist, a tension pneumothorax is generally considered to be present when a
pneumothorax (primary spontaneous, secondary spontaneous, or traumatic) leads to significant impairment
of respiration and/or blood circulation.[4] Tension pneumothorax tends to occur in clinical situations such as
ventilation, resuscitation, trauma, or in patients with lung disease.[3] The most common findings in people with
tension pneumothorax are chest pain and respiratory distress, often with an increased heart rate (tachycardia)
and rapid breathing (tachypnea) in the initial stages. Other findings may include quieter breath sounds on one

side of the chest, low oxygen levels and blood pressure, and displacement of the trachea away from the
affected side. Rarely, there may be cyanosis (bluish discoloration of the skin due to low oxygen levels), altered
level of consciousness, a hyperresonant percussion note on examination of the affected side with reduced
expansion and decreased movement, pain in the epigastrium (upper abdomen), displacement of the apex
beat (heart impulse), and resonant sound when tapping the sternum.[4] This is a medical emergency and may
require immediate treatment without further investigations (see below).[3][4]
Tension pneumothorax may also occur in someone who is receiving mechanical ventilation, in which case it
may be difficult to spot as the person is typically receiving sedation; it is often noted because of a sudden
deterioration in condition.[4] Recent studies have shown that the development of tension features may not
always be as rapid as previously thought. Deviation of the trachea to one side and the presence of
raised jugular venous pressure (distended neck veins) are not reliable as clinical signs.[4]

Cause
Primary spontaneous
Spontaneous pneumothoraces are divided into two types: primary, which
occurs in the absence of known lung disease, and secondary, which occurs
in someone with underlying lung disease. The cause of primary spontaneous
pneumothorax is unknown, but established risk factors include male
sex, smoking, and a family history of pneumothorax.[5] The various
suspected underlying mechanisms are discussed below.[1][2]

Secondary spontaneous
Secondary spontaneous pneumothorax occurs in the setting of a variety of lung diseases. The most common
is chronic obstructive pulmonary disease (COPD), which accounts for approximately 70% of cases.[5] Known
lung diseases that may significantly increase the risk for pneumothorax are

Type

Causes

Diseases of the
airways[1]

COPD (especially when emphysema and lung bullae are present), acute severe
asthma, cystic fibrosis

Infections of the
lung[1]

Pneumocystis pneumonia (PCP), tuberculosis, necrotizing pneumonia

Interstitial lung
disease[1]

Sarcoidosis, idiopathic pulmonary fibrosis, histiocytosis


X, lymphangioleiomyomatosis (LAM)

Connective tissue
diseases[1]
Cancer[1]
Miscellaneous[2]

Rheumatoid arthritis, ankylosing


spondylitis, polymyositis and dermatomyositis, systemic sclerosis, Marfan's
syndrome and EhlersDanlos syndrome
Lung cancer, sarcomas involving the lung
Catamenial pneumothorax (associated with the menstrual cycle and related
to endometriosis in the chest)

In children, additional causes include measles, echinococcosis, inhalation of a foreign body, and
certain congenital malformations (congenital cystic adenomatoid malformation and congenital lobar
emphysema).[6]

11.5% of people with a spontaneous pneumothorax have a family member who has previously experienced a
pneumothorax. The hereditary conditions--Marfan syndrome, homocystinuria, EhlersDanlos syndrome, alpha
1-antitrypsin deficiency (which leads to emphysema), and BirtHoggDub syndromehave all been linked to
familial pneumothorax.[7] Generally, these conditions cause other signs and symptoms as well, and
pneumothorax is not usually the primary finding.[7] BirtHoggDub syndrome is caused by mutations in
the FLCN gene (located atchromosome 17p11.2), which encodes a protein named folliculin.[6][7] FLCN mutations
and lung lesions have also been identified in familial cases of pneumothorax where other features of Birt
HoggDub syndrome are absent.[6] In addition to the genetic associations, the HLAhaplotype A2B40 is also a
genetic predisposition to PSP.[8][9]
Traumatic
A traumatic pneumothorax may result from either blunt trauma or penetrating injury to the chest wall.[2] The most
common mechanism is due to the penetration of sharp bony points at a new rib fracture, which damages lung
tissue.[5] Traumatic pneumothorax may also be observed in thoseexposed to blasts, even though there is no
apparent injury to the chest.[10]
Medical procedures, such as the insertion of a central venous catheter into one of the chest veins or the taking
of biopsy samples from lung tissue, may lead to pneumothorax. The administration of positive pressure
ventilation, either mechanical ventilation or non-invasive ventilation, can result in barotrauma (pressure-related
injury) leading to a pneumothorax.[2]
Divers who breathe from an underwater apparatus are supplied with breathing gas at ambient pressure, which
results in their lungs containing gas at higher than atmospheric pressure. Divers breathing compressed air
(such as when scuba diving) may suffer a pneumothorax as a result of barotrauma from ascending just 1 metre
(3 ft) while breath-holding with their lungs fully inflated.[11] An additional problem in these cases is that those with
other features of decompression sickness are typically treated in a diving chamber with hyperbaric therapy; this
can lead to a small pneumothorax rapidly enlarging and causing features of tension.[11]

Chest radiograph
A pneumothorax is, when looked for, usually relatively easily appreciated. Typically they demonstrate:

visible visceral pleural edge see as a very thin, sharp white line

no lung markings are seen peripheral to this line

the peripheral space is radiolucent compared to adjacent lung

the lung may completely collapse

the mediastinum should not shift away from the pneumothorax unless a tension pneumothorax is
present (discussed separately).

subcutaneous emphysema and pneumomediastinum may also be present


In cases where these features are not clearly present a number of techniques can be employed:

lateral decubitus radiograph:


o
should be done with the suspected side up
o
the lung will then 'fall' away from the chest wall

expiratory chest radiograph:


o
lung becomes smaller and denser
o
pneumothorax remains the same size and is thus more conspicuous : although some
authors suggest that there no difference in detection rate 6

CT scan
When imaged supine detection can be difficult: see pneumothorax in a supine patient, and pneumothorax is one
cause of a transradiant hemithorax.
Ultrasound

M-mode can be used to determine movement of lung within the rib-interspace. Small pneumothoraces are best
appreciated anteriorly in the supine position (gas rises) whereas large pneumothoraces are appreciated laterally
in the mid-axillary line.
PULSE OXIMETRY
SpO2 = oxygen saturation as measured by pulse oximeter indirect measurement of the oxygen content of
the blood NORMAL is over 93%
SaO2 = oxygen saturation as measured by blood analysis (e.g. a blood gas) direct measurement of the
oxygen content of the blood NORMAL is over 95%
PaO2 = partial pressure of oxygen in the blood, as measured by blood analysis NORMAL > 80mmHg
SaO2 is an invasive measure of the % of Oxyhemoglobin(oxygen saturated hemoglobin) in the blood using lab
tests on arterial blood. SpO2 noninvasive measure the % of saturated hemoglobin in the capillary bed and does
not identify what is saturating the hemaglobin. ie: carboxyhemoglobin, methemoglobin, ect. Typically(in a
healthy pt) SaO2 and SpO2 measure the same thing, but a difference can be found in patients with conditions
such as CO poisoning and rhabdomyolysis.
The normal value for the partial pressure of arterial oxygen (PaO2) irrespective of age is greater than 80

mmHg/10.6 kPa
The normal PaO2 for a given age can be predicted from: -

Seated PaO2 = 104mmHg/13.8 kPa - 0.27 x age in years ; Supine PaO2 = 104/13.8 - 0.42 x age.
If PaO2 is < 80 mmHg/10.7 kPa, the patient has arterial hypoxemia.

79 - 70 mmHg (10.6 - 9.4 kPa) = mild hypoxemia


69 - 60 (9.3 - 8.0 kPa)= moderate hypoxemia
59 - 50 (7.9 - 6.6 kPa)= severe hypoxemia
< 50 (6.6 kPa) = extreme hypoxemia
Normal values for PaCO2
o 35 - 45 mmHg ( 4.7 - 6.0 kPa)
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