FLAIL CHEST

FIRST AID Make sure the patient has a clear airway.

If he now breathes adequately, no further first aid is necessary.

If he is not breathing adequately, try the following methods of keeping the flail segment still until you find one which works.

(1) Gently press it with your hand.

(2) Turn the patient on to his side. This will: (a) keep the flail segment still, (b) keep his uninjured lung uppermost, and (c) prevent blood from his injured lung draining downwards into it.

Figure 65.10: TRACTION FOR A FLAIL CHEST. Towel clips (A) are usually the most convenient way to apply traction. Or, you can apply it with a Steinmann pin and a stirrup (B and C). If the patient has a severe open injury and is still alive, you can drill his ribs and pass a Kirschner wire through them (D and E). After de Palma and Peter Bewes.

(3) Support him with strapping or sandbags.

CAUTION! Don’t apply a pad or bandage, because this will only hide the abnormal movement, without stopping it. If necessary intubate him and inflate him with a self–inflating bag.

If possible, refer him.

If you cannot refer him, he will certainly need a chest drain and an underwater seal.

Treat his pain. Intercostal blocks (A 6.7) will help him. A single intravenous morphine injection may make a mildly blue, anoxic, sweating patient quiet and pink. Give it cautiously and don’t give more than is necessary.

PREVENTING PARADOXICAL MOVEMENT IN A FLAIL CHEST

Under local anaesthesia, use any of the following methods to apply traction to one, two, or more points on the floating part of the patient’s rib cage.

(1) Grip his flail ribs or sternum with several towel clips, or suitable forceps, and then tie these together with string. The clips or forceps must have a ratchet so that they remain closed.

(2) Pass wire or strong sutures under his ribs or sternum.

(3) Screw some sterile cup hooks into his ribs or sternum.

(4) Pass a Steinmann pin under his pectoral muscles close to his ribs, as in B, and C, Fig. 65-10.

Attach cords to any of these traction points, pass them over pulleys, and then tie weights to the cords. Usually, about 500 g per traction point is enough. You may need up to about 5 kg on either side. Fix the pulleys to a frame (70.9), as for fractures.

MANAGEMENT Pay great attention to the patient’s breathing. Encourage him to cough and clear his respiratory tract. If loud rhonchi show that fluid is accumulating, consider doing a tracheostomy (52.2).

If the patient’s breathing is ’rattly’ and he cannot cough, suck out his pharynx. If this fails to clear his airway adequately, try bronchoscopic suction.

If his breathing becomes very weak and shallow, resuscitate him with a self–inflating bag (A 13.1), especially during the first 24 hours.

If he is still bleeding after 24 hours, he needs a thoracotomy to find the bleeding point.

Continue traction until his chest moves as one piece when the weights are temporarily lifted.

DIFFICULTIES WITH A FLAIL CHEST

If a patient has a FLAIL STERNUM, this is particularly serious. He is in great pain and cannot cough, so he retains his bronchial secretions, and his lungs become oedematous. If you don’t have an Abrams pin, use any of the above methods to exert traction on his sternum. Cup hooks are useful.

If he is VERY FAT or muscular, traction will be difficult. You may need to expose his ribs and apply it to them directly.