What is the best management for a patient with post-traumatic (RTA) chest trauma, centralized trachea, paradoxical movement of left ribs, and radiographic evidence of rib fractures and hemithorax, with hypoxemia (pO2 90%)?

Management of Post-RTA Chest Trauma with Flail Chest and Pleural Collection

Tube thoracotomy (option B) is the definitive and best management for this patient with post-RTA chest trauma showing paradoxical movement of ribs, blurred costophrenic angle, and hypoxemia. 1

Clinical Assessment and Rationale

The patient presents with:

• Post-RTA chest trauma
• Centralized trachea
• Paradoxical movement of left ribs 6,7,8 (indicating flail chest)
• X-ray showing rib fractures and blurred costophrenic angle (suggesting pleural collection)
• Hypoxemia (pO2 90%)

This presentation strongly indicates a hemothorax or pneumothorax requiring immediate drainage to improve oxygenation and prevent further respiratory compromise.

Management Algorithm

1. Initial Intervention: Tube Thoracotomy

   • Immediate tube thoracotomy is indicated due to the blurred costophrenic angle on X-ray, suggesting pleural collection 1
   • This provides immediate drainage of accumulated blood or air, improving lung expansion and oxygenation

2. Respiratory Support Assessment

   • After tube thoracotomy, reassess respiratory status
   • If respiratory failure persists despite tube thoracotomy, consider escalation to mechanical ventilation 1
   • The paradoxical movement of ribs indicates flail chest, which may require ventilatory support if oxygenation does not improve with tube thoracotomy

3. Ongoing Management

   • Provide adequate pain control using multimodal analgesia
   • Implement careful fluid management
   • Ensure pulmonary toilet (chest physiotherapy)
   • Monitor for complications such as persistent air leak, inadequate drainage, or infection 1

Why Not Other Options?

• Intubation and mechanical ventilation (option A): While this may be necessary if the patient deteriorates after tube thoracotomy, it is not the first-line intervention. The European Respiratory Society guidelines suggest that NIV or mechanical ventilation should be considered only after addressing the underlying pleural collection 2, 1. Immediate intubation without addressing the pleural collection would not resolve the underlying problem.

• Adhesive strap (option C): This is inadequate for managing flail chest with pleural collection. Adhesive strapping was historically used for rib fractures but is now considered ineffective and potentially harmful for flail chest as it restricts chest wall movement and impairs secretion clearance.

Evidence Strength and Considerations

The World Society of Emergency Surgery (WSES) and Chest Wall Injury Society (CWIS) guidelines strongly recommend evaluating patients with flail chest for pneumothorax/hemothorax and performing tube thoracostomy if there is evidence of pleural collection 1. This is supported by multiple trauma management guidelines that emphasize the importance of immediate drainage for blurred costophrenic angles on X-ray 1, 3.

Potential Complications to Monitor

• Persistent air leak
• Inadequate drainage
• Infection
• Tube dislodgement
• Progressive respiratory failure 1

If the patient fails to improve after tube thoracotomy, consider surgical stabilization of rib fractures (SSRF), particularly for persistent flail chest with severe respiratory compromise 2, 1.