How should a prehospital medic manage a patient with flail chest?

Prehospital Management of Flail Chest

Immediate Life-Threatening Priorities

Control paradoxical chest wall movement immediately, maintain airway patency, provide high-flow oxygen, and implement aggressive pain control—these four interventions form the foundation of flail chest management and directly prevent respiratory failure and death. 1

Step 1: Mechanical Stabilization of the Chest Wall

• Apply pressure dressing with pads directly over the flail segment to control paradoxical movement, particularly if the segment measures 3-5 cm, as this degree of movement causes severe respiratory and circulatory compromise that can rapidly lead to death 1
• Secure the chest with a multi-head chest strap for temporary external fixation after pad placement 1, 2
• If the flail segment is limited or located posteriorly, a local pad with pressure dressing may suffice 1

Step 2: Airway and Oxygenation

• Provide high-flow oxygen at minimum 10 L/min with target SpO2 >94% to prevent hypoxemia from underlying pulmonary contusion 1, 3
• Maintain airway patency and prepare for potential need for positive pressure ventilation if respiratory distress develops 1

Step 3: Aggressive Pain Management

• Pain control is paramount and directly impacts mortality by preventing respiratory splinting, atelectasis, and pneumonia 2, 4
• Administer IV acetaminophen 1000mg immediately as first-line analgesia 2, 5
• Consider low-dose ketamine (0.3 mg/kg IV over 15 minutes) as an alternative to opioids, providing equivalent analgesia without respiratory depression 5, 3
• Use opioids sparingly and only for breakthrough pain, as respiratory depression is particularly dangerous with underlying lung contusion 2, 5

Step 4: Fluid Management Strategy

• Ensure adequate tissue perfusion initially without fluid restriction, but once the patient is resuscitated, avoid unnecessary fluid administration to prevent worsening pulmonary contusion 1
• Limit maintenance fluids to 100-200 mL/hour after initial resuscitation 3

Critical Assessment for Associated Injuries

Rule Out Obstructive Shock Immediately

In flail chest with hypotension and tachycardia, assume tension pneumothorax or massive hemothorax first—these are the immediate killers that require intervention before transport. 2, 3

• Assess for tension pneumothorax: progressive dyspnea, attenuated breath sounds, tracheal deviation, jugular venous distension 1, 3
• Assess for massive hemothorax: chest pain, shortness of breath, shock, percussion dullness on the injured side 1, 3
• If tension pneumothorax is suspected, perform needle decompression at the second intercostal space, midclavicular line using 14-gauge, 8.25 cm needle 3
• If massive hemothorax is suspected, prepare for tube thoracostomy at the fourth/fifth intercostal space, midaxillary line 1

Exclude Pericardial Tamponade

• In penetrating or severe blunt chest trauma with hypotension, consider pericardial tamponade 1, 2
• Look for Beck's triad: distant heart sounds, jugular venous distension, hypotension (though these are difficult to assess in the field) 1

Transport Considerations

• Classify as Priority 1 (urgent evacuation) for progressive respiratory failure, suspected cardiac injury, or combined thoracoabdominal wounds 3
• Monitor closely for development of tension pneumothorax during transport, especially if positive pressure ventilation is initiated 1
• Position patient upright if possible to optimize respiratory mechanics 5

Common Pitfalls to Avoid

• Undertreatment of pain is the most common error, leading to shallow breathing, atelectasis, and pneumonia 2, 4
• Overreliance on opioids causes respiratory depression, which is particularly dangerous with underlying pulmonary contusion 2, 5
• Failing to recognize tension pneumothorax or massive hemothorax as the cause of hypotension in isolated chest trauma—these obstructive causes must be excluded before attributing shock to other sources 2, 3
• Excessive fluid administration after initial resuscitation worsens pulmonary contusion and respiratory failure 1, 3
• Delaying transport for definitive care—flail chest patients require hospital admission for surgical stabilization consideration within 48-72 hours 2, 5

Definitive Care Handoff

• Communicate to receiving facility: mechanism of injury, degree of paradoxical movement, associated injuries identified, interventions performed, and response to treatment 2
• Emphasize need for early surgical stabilization evaluation within 48-72 hours, as this significantly reduces pneumonia, mechanical ventilation duration, and mortality 2, 5