What is the treatment for a patient with flail chest?

Treatment of Flail Chest

Surgical stabilization of rib fractures (SSRF) should be considered in all flail chest patients as the primary treatment approach. 1

Definition and Clinical Presentation

• Flail chest is a clinical finding characterized by paradoxical movement of a chest wall segment during respiration, resulting from a contiguous segment of 3 or more consecutive ribs fractured at 2 or more places 1
• Patients typically present with rapid breathing, respiratory distress, paradoxical chest wall movement, and may develop shock, especially when combined with pulmonary contusion 1
• This condition is associated with high morbidity and mortality rates, with mortality reaching up to 16% in trauma patients 2

Initial Management

1. Immediate Stabilization:

   • Control paradoxical chest wall movement as soon as possible 1
   • Maintain airway patency and provide adequate oxygen supply 1
   • Correct respiratory and circulatory dysfunction to prevent shock 1
   • For limited or posterior flail segments, apply a pressure dressing with pads temporarily 1
   • Consider chest fixation with a multi-head chest strap for immediate stabilization 1

2. Pain Management:

   • Implement aggressive pain control measures, as adequate analgesia is crucial for recovery and restoration of normal respiratory mechanics 3
   • Consider regional anesthesia techniques such as intercostal nerve blocks 4
   • If pain remains severe despite treatment, this may be an indication for surgical intervention 1

Definitive Treatment Options

1. Surgical Stabilization of Rib Fractures (SSRF)

SSRF is the preferred treatment approach for flail chest patients based on the most recent evidence 1:

• Indications for SSRF in flail chest:

  • All flail chest patients should be considered for SSRF 1
  • Especially beneficial for anterolateral flail segments with displacement 1
  • Patients with respiratory failure without severe pulmonary contusion 1
  • Patients with pulmonary contusion and persistent chest wall instability or weaning failure 1
  • Non-intubated patients with deteriorating pulmonary function 1

• Benefits of SSRF compared to non-operative management:

  • Lower incidence of tracheostomies (11% vs 37%) 5
  • Reduced pneumonia rates (15% vs 50%) 5
  • Shorter mechanical ventilation duration (3.9 days vs 15 days) 5
  • Decreased ICU stay (9 days vs 21 days) 5
  • Lower mortality rates (8% vs 29%) 5
  • Better long-term pulmonary function and reduced chest wall deformity 1
  • Reduced long-term complaints of chest tightness, pain, and dyspnea 1
  • More cost-effective despite the added surgical expense 1

2. Non-Operative Management

For patients who are not candidates for SSRF or when SSRF is not available:

• Conservative Respiratory Support:

  • Aggressive pulmonary toilet including facemask oxygen, CPAP, and chest physiotherapy 3
  • Fluid restriction, diuretics, and albumin administration to manage pulmonary contusion 4
  • Vigorous pulmonary toilet to prevent atelectasis and pneumonia 4

• Mechanical Ventilation:

  • Consider for patients with refractory respiratory failure or other serious traumatic injuries 3
  • Be aware that prolonged mechanical ventilation is associated with increased pneumonia risk and poorer outcomes 3
  • Consider early tracheostomy and frequent flexible bronchoscopy for effective pulmonary toilet in ventilated patients 3

Special Considerations

• Pediatric Patients: Surgical management may reduce days of mechanical ventilation and hospitalization in pediatric flail chest cases 6

• Pulmonary Contusion: The presence of severe pulmonary contusion may limit the immediate benefits of SSRF on ventilator time and ICU stay 1

• Multidisciplinary Approach: SSRF is optimal in dedicated centers with a multidisciplinary team that has developed protocols for both operative and non-operative management 1

Common Pitfalls to Avoid

• Focusing only on paradoxical motion: Treatment should address both the chest wall instability and underlying pulmonary contusion 4

• Delayed surgical intervention: When indicated, early SSRF provides better outcomes than delayed intervention 1

• Prolonged mechanical ventilation: This approach alone is associated with higher rates of pneumonia (50% vs 15%), septicemia (24% vs 4%), and mortality (29% vs 8%) compared to surgical fixation 5

• Inadequate pain control: Poor pain management leads to shallow breathing, retained secretions, and increased risk of pneumonia 3