Flail Chest MP Shah - Ccu
Flail Chest MP Shah - Ccu
Flail Chest MP Shah - Ccu
NAIROBI CAMPUS
20/03/2019
Hb - Haemoglobin
HCT - Haematocnt
Na+ -Sodium
RR -Respiration rate.
K+ -Potassium.
BE -Base excess.
HCO3 -Bicarbonates.
CT -Computed Tonogtaphy
BP -Blood pressure
Kpa -Kilopascals.
4
INTRODUCTION
The case study was carried out at M.P. Shah Hospital critical care unit. The hospital is Located in
Parklands Area in Nairobi County, M.P. Shah Hospital is a modern 210-bed facility which is
home to highly skilled and experienced specialists and professional medical staff. MP Shah
Hospital has been recognized as a national referral facility with ISO 9001:2015 quality
Southern Africa), an independent body that fosters postgraduate education in surgery and
VISION
The hospital’s vision is “Determination and selfless concern for the well-being of the
community”.
Mission
The mission is to provide Patient centered care driven by values of the social service league
Description of placement
M.P Shah’s Critical Care Unit is located at the ground floor proximal to the main entrance. It has
8 rooms where 2 are designated for isolation cases. It is equipped with 8 ventilator machines and
10 monitors. The CCU has a water system flow for dialysis patients and a total of 21 CCU
trained nurses inclusive of the nurse in charge and her deputy. It has 5 support staff and 2
intensivists who work on call basis in collaboration with the medical staff who are always in
bedside-working shifts of 12 hours. It is also a learning unit to healthcare students from various
institutions. The most common cases are chronic pulmonary diseases, kidney and chest injuries.
5
The patient of this study is male, 35 years of age who was admitted on 23.03.2019 with a
diagnosis of Flial-chest injury due to Road traffic accident (RTA). He was brought to the hospital
by the police and a good samaritan who rescued him from his car after the accident. They arrived
THE CASE
Name: L.M.N
Age: 35 years
Sex: Male
Nationality: Kenyan
Religion: Christian
Residence: Allsops
Occupation: Businessman
Relationship: Wife
Ward: CCU
D.O.A: 23.03.2019
Chie complains
Patient had frank bleeding from the nose and difficulty in breathing with low levels of
consciousness.
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Patients was involved in an accident at Thika road on 23th march 2019 where he was hit by an
over speeding personal car in attempt to change lanes on the road on his way back home from
work. He was rushed to Hospital by good Samaritans as he had sustained multiple traumas.
L.M.N had never been hospitalized or undergone any operations before. He had no history of
allergies to food and drugs but only minor ailment which were treated in out – patients
departments.
L.M.N is 2nd born in a family of 4 siblings – 2 boys 2 girls all siblings alive and well. His parents
live at Narok County. Nobody in the family has any chronic illness like diabetes, hypertension or
His father and mothers are both secondary school teachers in Narok county schools. His elder
brother is also a teacher in Nairobi – Embakasi and the two sisters are still in College at Narok
County.
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PHYSICAL EXAMINATION
a. Central Nervous System: Patient had low conscious levels opening his eyes, with pupil
His total GCS (Glasgow coma scale) was 9/15 Eye opening 5, verbal response 2, monitor
response 2.
b. Cardiovascular System: patient was connected to a continuous cardiac monitor and had
sinus tachycardia rhythm, Bp. 96/60 mmHg, pulse 90b/m cardiac sounds S¹ and S² both
normal and well heard. Peripheral pulses were all felt, capillary refill & 3 seconds in all
extremities Hb.12.2.g/dl.
c. Respiratory System: Patient was put on oxygen via Non – rebreathe mask, has
spontaneous breathing 28c/min. chest shape was barrel with paradoxical movements
noted media sternum shifting to the right side , asymmetrical chest expansion, abnormal
tactile and vocal fremitus with crepitation heard on auscultation SPO² 96% with minimal
secretions.
d. Gastro- intestinal System: Abdomen was tender and distended and painful especially on
e. Skin and Muscular skeletal System: Patient had intact skin; body temperature of 36◦c
skin was a bit clammy though warm. His upper and lower extremities were very weak.
Plan was prepare for theatre for splenic repair, intubation, Foley catheter insertion,
Nasogastric tube insertion, ABGA’s, Monitor closely vitals and input and output.
8
Several investigations were done on patient L.M.N. Some of the investigations include;
Blood gases analysis < arterial> - This was done daily for the entire stay in c.c.u.
Coagulation tests.
Patient was prepared and taken to theatre for emergency laparotomy (spleen repairment) on 23rd March 2019 at
3.00p.m.
23/03/2019.
At 3.30p.m warded back in C.C.U. intubated C.V.C and chest tube in situ. Nasogastric tube inserted, put on
mechanical ventilation IPPV under sedation. Feeding commenced after nutritional review fresubin 83m/s/hr,
Nursed in head elevation 30◦ degrees up. Input and output measuring of all drains. Other nursing care
commenced; bed bath, feeding, pressure area care, drug administration, oral and invasive site care,
psychological care, vital signs monitoring and suctioning 4 hourly/ PRN. Plan .Antibiotic coverage, Analgestic
treatment and ulcer prophylaxis. BP 100/60 mmHg pulse 82bpm RR 24c/min Temperature 36◦c commenced
24/03/2019.
PH ̄ 7.24, PCO² - 5kpa. PO² 16.6 kpa, HCO³ 18.8 mmo/l BE – 3.8, Na˖136m/l K˖ 3.5 mmo/l Hb – 6.4g/dl,
RBS 5.9 mmo/l. Metabolic acidosis uncompensated with Aneamia GCS 10т/15.
Plan: Transfuse 2 pints of whole blood, grouping and cross matching intravenous fluids. Normal saline with iv
5% Dextrose alternate and ventilation mode changed to SIMV Tidal volume 500m/s , Fraction of inspired
oxygen 60% RR. 14 dm/n PEEP 5.12.30 p.m. First pint of blood transfusion commenced and ended up at 3.20
10
p.m then second pint commenced at 4 p.m ended up at 8 p.m with no adverse reaction. Then put on intravenous
25/03/2019.
Patient reviewed by C.C.U doctors team, commence on clexane 40mg OD, sub – cutaneously, sedation with
dormicum to commence and continued with other previous medication and SIMV mode of mechanical
Plan: Liver function, coagulation and Electrolytes tests. Arterial blood gases within normal limits and Hb
26/03/2019
Patient still on mechanical ventilation SIMV mode, Mechanical, nursing care and physiotherapy continued.
GCS IOT/15 good input output chest drain active, passing loose stool doctor ordered for culture and
sensitivity. Tests previously done; Liver function test, urea and electrolytes test, coagulation test and arterial
27/03/2019.
Review by doctors’ team, chest drain reviewed and site well secured. Culture and sensitivity test for stool was
negative plan; continue medical, nursing care and physiotherapy. Nutrition review by unit nutrionist added
28/03/2019.
Patient L.M.N getting continued medical and nursing care, on doctors review during ward round; has good
bilateral air entry, hemodynamic within normal ranges. Put on CPAP. (Continuous positive Airway pressure
mode) parameters as follows; fraction of inspired oxygen 35% PEEP 8 other settings maintained. GCS 10т/15.
Plan, wean off sedation immediately, for thermo vent if prognosis is satisfactory.
29/03/2019.
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Patient showing great improvement, daily nursing medical care continued GCS 10т/15 Normal vital signs and
arterial blood gases. Nutritional, physiotherapy and skin care done daily.
30/3/2019.
Reviewed during doctors ward round, put on thermo vent oxygen 3 litres, chest is clear and GCS 10т/15. SPO²
98%.
31/03/2019.
Patient L.M.N improving remarkably, able to sit on the bed and having good input and output, GCS 10т/15 on
Daily physiotherapy, nursing, medical, and psychological care. Extubated, physiotherapy and nebulization
done put on simple face mask with oxygen 1litre SPO² 100%. Able to talk and well oriented post extubation
1/04/2019.
Patient L.M.N discharged to ward 4B for continuous monitoring and evaluation patient was observed for a
2/04/2019. Patient was discharged home through surgical clinic and went home, was given appointment every
injuries and is likely the most common serious injury to the thorax seen by clinicians.
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Specific procedures
a. Intubation and mechanical ventilation, to provide optimum ventilation, gaseous exchange and
prevent respiratory failure. Since patient had chest injury and resulted in paradoxical movement and
respiratory distress.
b. Nasogastric tube insertion and feeding to maintain good nutritional status since patient had general
parenteral feeding and measurement of central venous pressure to check hydration status.
d. Chest tube insertion under water seal drainage; to monitor status of the draining output,
fluctuations, Amount, colour in order to take immediate actions incase of any abnormalities.
e. Close observation using cardiac monitor; to rule out any deviation from normal limits, and monitor
f. Total nursing care done since patient was bedridden, includes; feeding and elimination care,
pressure area care, oral and CVC site care, skin care, suctioning, monitoring input, output,
Family involvement.
Patient L.M.N parents and siblings were deeply involved in his care by ensuring all of L.M.N’s needs were
met and daily psychological care. This includes, buying drugs which were not available in the hospital,
buying him feeds like mala and also petroleum jelly for skin care.
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Team co-ordination
There was good collaboration in all the health workers in C.C.U and ensured optimal patient care.
Doctors; reviewed him daily adjusting medications and also surgical care/ procedures like C.V.C insertion,
Nurses; Played a big role by giving optimal care to meet all patient needs and acting as patients advocates.
Physiotherapists; Attended to him daily ensuring airway patency and providing continuous range of
motion exercises.
Laboratory technologists; carried lab request according especially on arterial blood gases analysis, RBS,
Hb on daily basis.
Support staff; Ensured clean and conducive environment for patient, health care workers and relatives.
Follow up care.
Patient L.M.N was discharged from C.C.U to ward 4B for further management and continuous observation.
There after was discharged home after a week through surgical outpatient’s clinic to be coming once every
week.
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DRUG INDEX
Clexane
Classifications: Anticoagulant.
Mode of action: stops new clots formations and stops further growth of existing clots.
Side effects: BL.M.Nding, severe headaches, back pain, CI bL.M.Nding bruises and tender swollen
areas.
Zantac/ Ranitidine
Mode of action: It works by reducing amount of acid produced by stomach and intestines.
Side Effects: Chest pain, fever, easy bruising, bL.M.Nding, bracycardia/ tachycardia, vision problems, sore
Diazepam
Classification: Benzodiazepines.
Indication: Treats anxiety, acute alcoholic withdrawal, seizures, muscle spasm relief.
Paracetamol (Acetaminophen).
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Morphine Sulphate.
Relieves pain.
Indication: Trauma, post surgery, celebral vascular accident, coronary artery disease.
Ranferon
Classification: Heamatinic.
Meropenem
Elevate heart Altered comfort To keep patient Patient To allay Patient becomes calm
rate above 100 related to pain comfortable and commenced on agitation and and restful heart rate
beats / minute manifested by stabilize the sedatives and ventilation lowers but within normal
patient is patient being heart beat. analgesics. dysynchrony limits.
restless and restless, Dorminicum/ and block
agitated. Agitated and morphine infusion pain receptor
increase heart at 5m/s hour. site and
rate. prevent
vasospasms.
Patient looks Fear and To allay anxiety Engaging patient Counseling Patient and family
irritable and anxiety related and decrease in his care, session with members are able to cope
terrified. to fear of fear. explaining every unit and adjust to the
Relatives seem impencting procedure and its counselor to situation.
to despair. doom. purpose. relieve
anxiety and
demystify
believes /
myths on the
condition an
I.C.U stay.
Knowledge Patient and Explaining to To provide Patient and relatives
Relatives and deficit related to Relatives to relatives and adequate calmness and co-
Patient ask too disease process have detailed patients about the knowledge of operation obtained.
many as evidenced by knowledge of disease process, its the
questions patient asking the disease and management and condition.
about the too many possible possible outcomes.
condition and questions. outcomes.
prognosis.
LITERATURE REVIEW
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Definition
Chest wall injury is an extremely common following blunt trauma. It varies in severity
from minor bruising or an isolated rib fracture to severe crush injuries of both hemi
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
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
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
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 pulmonary contusions
underneath.
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MANAGEMENT
Management of chest wall injury is directed towards protecting the underlying lung and allowing
adequate oxygenation, ventilation and pulmonary toilet. This strategy is aimed at preventing the
development of pneumonia, which is the most common complication of chest wall injury.
Note that while a young fit patient will easily manage one or two rib fractures with simple
analgesia, the same injury in an elderly patient is regarded as major and will frequently lead to
pneumonia and respiratory failure if not appropriately managed (and even then).
Oxygenation
All patients should initially be placed on 100% oxygen via a non-rebreathe facemask and
consider intubation.
Analgesia
Analgesia is the mainstay of therapy for rib fractures. While strapping the chest to splint rib
fractures may seem like a good idea, it impedes chest wall movement and prevents adequate
inspiration and clearance of secretions. Opioid analgesics are useful, but when used as the sole
analgesic agent may require such high doses that they produce respiratory depression - especially
in the elderly.
Patient controlled administration of an opioid infusion (PCA) is the best method for cooperative
patients. The addition of a non-steroidal anti-inflammatory agent may provide adequate relief,
but these should be withheld until other injuries have been excluded (eg. traumatic brain injury)
Undoubtedly the best analgesia for a severe chest wall injury is a continuous epidural infusion of
a local anaesthetic agent (+/- an opioid). This provides complete analgesia allowing normal
inspiration and coughing without the risks of respiratory depression. Epidurals may be placed in
Other methods of local anaesthetic administration are available, but are poor in comparison to an
epidural. For one or two isolated rib fractures, posterior rib blocks may be appropriate. Local
anaesthetic is infiltrated around the intercostals nerve posteriorly. These blocks will last 4-24
hours and will then have to be repeated. Where a chest tube is present, some practitioners
advocate instilling a local anaesthetic solution into the pleural splace. However the volume
needed is large, the results very variable and local anaesthetic toxicity due to rapid pleural
absorptionpossibility.
Intubation and mechanical ventilation is rarely indicated for chest wall injury alone. Where
Positive pressure ventilation may be required for severe chest wall instability resulting in
Intubation and ventilation may be required when anesthesia is necessary to provide immediate
Ventilation is usually necessary only until the resolution of the pulmonary contusion. Healing
and stabilization of rib fractures is rarely the limiting step in weaning from mechanical
Patients with rib fractures who receive positive pressure ventilation are at an increased risk of
developing a pneumothorax or tension pneumothorax due to laceration of the lung by the sharp
fracture end.
Many authors recommend placement of a prophylactic chest tube for all patients with rib
fractures who receive mechanical ventilation. This practice varies depending on the presence of
other injuries, monitoring environment and available resources. For example, the patient with
isolated chest injuries with continuous cardiorespiratory monitoring in an intensive care unit can
probably be observed without a chest tube. In contrast, in a patient anaesthetized for prolonged
surgery, placement of a prophylactic chest tube may be more appropriate. Especially where the
The popularity of rib fracture fixation has waxed and waned over the past 5 decades. External
fixation and stabilization was common for large chest wall injuries prior to the development of
Positive pressure ventilation essentially provides an 'internal stabilization' to the thoracic cage as
well as improving oxygenation and ventilation for the management of pulmonary contusion.
Hence it has essentially replaced fracture fixation over the past twenty years. In the last few
years however a few studies have suggested that some groups of patients (as yet unidentified)
may benefit from early fracture fixation, allowing earlier weaning from mechanical ventilation
Radiological Examination
a. Chest X-ray
The anterior-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.
seen on chest X-ray will almost always be associated with a rib fractures, whether or not
identified clinically or by X-ray. In pediatric patients the ribs are more pliable and less
likely to fracture, although there will still be significant contusion of chest wall
structures.
b. Computed Tomography
Computed tomography provides very little further clinical information and is not indicated for
2.6 Complications
Respiratory failure
Cardiac failure
Hypovolemic shock
N/B: what is a paradoxical movement? Pulmonary contusions are commonly associated with
flail chest and that can lead to respiratory failure. This is due to the paradoxical motions of the
chest wall from the fragments interrupting normal breathing and chest movement.
When a patient has a flail chest there is paradoxical chest wall movement what is the effect of
Falls account for 14% of flail chest injuries. This typically occurs when three or more adjacent
ribs are fractured in two or more places, allowing that segment of the thoracic wall to displace
Two of the major symptoms of flail chest are chest pain and dyspnea
Others include: mediastina shift to affected site , use of accessory muscles ,increased work of
Pathophysiology
The characteristic paradoxical motion of the flail segment occurs due to pressure changes
During normal inspiration, the diaphragm contracts and intercostal muscles pull the rib
cage out. Pressure in the thorax decreases below atmospheric pressure, and air rushes in
through the trachea. The flail segment will be pulled in with the decrease in pressure
During normal expiration, the diaphragm and intercostal muscles relax increasing internal
pressure, allowing the abdominal organs to push air upwards and out of the thorax.
However, a flail segment will also be pushed out while the rest of the rib cage contracts.
The constant motion of the ribs in the flail segment at the site of the fracture is extremely painful,
and, untreated, the sharp broken edges of the ribs are likely to eventually puncture the pleural sac
and lung, possibly causing a pneumothorax. The concern about "mediastinal flutter" (the shift of
the mediastinum with paradoxical diaphragm movement) does not appear to be merited.
Pulmonary contusions are commonly associated with flail chest and that can lead to respiratory
failure. This is due to the paradoxical motions of the chest wall from the fragments interrupting
Typical paradoxical motion is associated with stiff lungs, which requires extra work for normal
breathing, and increased lung resistance, which makes air flow difficult.
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The respiratory failure from the flail chest requires mechanical ventilation and a longer stay in an
intensive care unit. It is the damage to the lungs from the flail segments that are life-threatening.
Prevalence
Approximately 1 out of 13patientsadmitted to the hospital with fracturedribs are found to have
Results
The death rate of patients with flail chest depends on the severity of their condition ranging from
Causes
The most common reason for flail chest injuries are vehicle accidents, which account for 76% of
Another main cause of flail chest injuries results from falling which is mainly elderly related.
The elderly are more impacted by the falls as a result of their weak and frail bones, unlike their
younger counterparts who can fall without being impacted as severely. Falls account for 14% of
Rollover and crushing injuries most commonly break ribs at only one point– for flail chest to
occur a significant impact is required, breaking the ribs in two or more places. This can be caused
by a significant fall, car accident or other forceful accidents. In the elderly, it can be caused by
In children, the majority of flail chest injuries can be a result of the common blunt force traumas
The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along
the mid lateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines)
may result.
Multiple care patterns and treatment modalities have emerged, many based on anecdotal clinical
observation and evidence. Within the last 20 years, more rigorous scientific methods have been
applied to the problem of flail chest, in both the clinical setting and laboratory. More advanced
radiologic work-up with multislice computed tomography (MSCT) scanners is increasing the
frequency of diagnosis of this problem. This article reviews the most salient data of the recent
literature and discusses some of the diagnostic and treatment options that are now available in
Severe blunt injury to the chest continues to be one of the leading causes of morbidity and
mortality in both young and old trauma victims .Flail chest is one of the worst subset of these
Recommendations.
The hospital care given to patient L.M.N was good and yielded good results but some considerations are
Doctors ward round should to be done early enough in order to attain new adjustments on time and avoid
Critique
Flail chest is a very fatal and critical condition. It’s said that most patients with flail chest end up with
respiratory failure and die. However the care given to patient L.M.N was prompt and excellent.
Conclusion
He recovered well without any complications due to the good team work among health workers in the unit.
This case study enabled me to learn more about chest injuries in this case heamothorax and flail chest and
dispute the belief that almost all patients with this condition die.
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References
1. JayleJayle, C. P., Allain, G., Ingrand, P., Laksiri, L., Bonnin, E., Hajj-Chahine, J., ... &
Corbi, P. (2015). Flail chest in polytraumatized patients: surgical fixation using Stracos
2. Schulz-Drost, S., Grupp, S., Pachowsky, M., Oppel, P., Krinner, S., Mauerer, A., ... &
Surgery, 43(2), 169-178.
3. Schuurmans, J., Goslings, J. C., & Schepers, T. (2017). Operative management versus
4. Zhang, Y., Tang, X., Xie, H., & Wang, R. L. (2015). Comparison of surgical fixation and
5. Xu, J. Q., Qiu, P. L., Yu, R. G., Gong, S. R., Ye, Y., & Shang, X. L. (2015). Better short-
term efficacy of treating severe flail chest with internal fixation surgery compared with