CABILATAZAN, Enjelaine L.

BSRT-II May 10, 2020

FLAIL CHEST SCORE:40/50

Part I: Case Report Review
A) Patient Information
CONTENT: 20/25 ORGANIZATION: 12/15
MECHANICS: 8/10
COMMENTS: I though the image on the mechanism of Flail Chest was good, however, no discussion was found. Also,
the discussion has few to little correlation. Also, the case has lacking info to accurately picture the patient’s condition
making the lab findings quite out of place. Also, the labs in the case should have been explained in the discussion like
the Creatinine Kinase and the specific Muscle Enzyme which I think is Myoglobin

A two-and-a-half-year-old male pedestrian was hit by a car and was transported to a hospital by air
ambulance. The patient weighs 14 kg and a height of 86 cm. There were no stated medical, family and
psychosocial history of the patient.

Upon arrival at the hospital they checked his Glasgow Coma Scale and has a score of 11 (ye 3;
verbal 3; motor 5). Both of his pupils measured 3 mm and pupillary reflexes were normal. Breathing
activity? Gross accidental injuries?

B) Clinical Findings

The patient’s physical examination revealed a body temperature of 37.6 °C, respiratory rate of 41
breaths/min, heart rate of 156 bpm and blood pressure of 106/47 mm Hg and detected a paradoxical
movement of his left thorax. Other review findings? Is the patient Responsive?

C) Diagnostic Assessment

The patient’s laboratory investigations revealed an inflammatory process and muscle deviation
enzyme which one? Is it really muscle deviation? consistent with blunt trauma. His serum creatinine
kinase level was elevated at 1229 IU/L. Analysis of the arterial blood gas of the patient on 100%
oxygen are as follows: pH: 7.28, PaO 2: 73.7 mm Hg, PaCO2: 49.3 mm Hg, HCO 3-: 22.5 mmol/L, base
excess of 3.6 mmol/L, and lactate of 14 mg/dL. Chest tomography (CT) was performed on the patient
and revealed bilateral lung contusions, left pneumothorax and fractures of the left clavicle and left third
to fifth ribs. Based on these findings and in addition to the paradoxical movement of the patient’s left
thorax, flail chest was diagnosed. The patient also had liver injury and traumatic subarachnoid
hemorrhage and he has an injury severity score (ISS) of 29.

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CABILATAZAN, Enjelaine L. BSRT-II May 10, 2020

Chest CT of patient on Admission.  a  Two-dimensional axial CT scan showed lung contusions (white arrows)
and left pneumothorax (red arrows).  b  Three-dimensional reconstruction of the CT scan showed fractures of the
left clavicle and the third to fifth ribs on the left (red arrows).

D) Therapeutic, Patient Outcome and Follow-up

The patient was intubated using 4 mm cuffed endotracheal tube. The ventilation mode was set to
synchronized intermittent-mandatory ventilation (SIMV) pressure-control and pressure-triggered
ventilation. The initial ventilator settings were: inspiratory time 0.7 s, RR of 20 breaths/min, pressure
control (PC) 17 cmH2O, pressure support (PS) 10 cmH2O, positive end expiratory pressure (PEEP) of 9
cmH2O and FiO2 of 0.4. No significant improvement were recorded in the following days but on the 8 th
day the PaO2/FiO2 (P/F) ratio improved from 73 on admission to 375, the lung contusions had also
improved on chest CT, the patient’s ventilatory mode was set to continuous positive airway pressure
(CPAP) and requires minimal ventilatory support. On the 9 th day, the paradoxical movement on the
patient’s left thorax has resolved and was extubated.

The patient’s condition was stable after extubation and was transferred to a local hospital for
rehabilitation on day 19.

Since it is a pediatric patient it is advisable to select intubation and mechanical ventilation

treatment because the functional residual capacity is smaller and the thorax is pliable due to high
thoracic compliance.

Reference:

Yasuda, R. et.al. (2015). Comparison of two pediatric flail chest cases.Scandinavian Journal of

Trauma, Resuscitation and Emergency Medicine v.23

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CABILATAZAN, Enjelaine L. BSRT-II May 10, 2020

Part II: Discussion

A) Epidemiology

Flail chest is a traumatic condition of the thorax that occurs when 3 or more ribs are broken in at
least 2 places. A flail chest arises when these injuries cause a segment of the chest wall to move
independently of the rest of the chest wall. Since it is a traumatic disorder, risk factors include risk
factors of major trauma. Motor collisions are the major cause of of the major trauma that results to flail
chest with 75%. Falls that occur particularly in elders cause another 15%. Flail chest is relatively
uncommon in children. It occurs when a segment of the chest wall is destabilized when several
adjacent ribs are fractured.

B) Pathology

The most common cause of flail chest is blunt chest trauma. As mentioned above, flail chest is
usually seen after automobile accidents and falls although it may also develop after aggressive
cardiopulmonary resuscitation or in patients with pathologic rib fractures. In children, flail chest is
infrequent, thus, if a child does have a flail chest it signifies a much greater degree of trauma. Flail
chest is usually associated with lung contusion that impairs the gas exchange and decreases the
compliance. Aside from pulmonary contusion, the patient may also experience ineffective ventilation
due to increase deadspace; hypoventilation and atelectasis are the result of pain and injury wherein
the pain causes splinting that decreases the tidal volume and predisposes to the formation of
atelectasis. One of the most important sign seen in a patient with flail chest is the paradoxical
movement of the affected area of the chest. While the rest of the chest wall moves outward, the flail
segment moves inward. With flail chest, the continuity of the chest wall is disrupted and the physiologic
action of the ribs is altered.

C) Diagnostics

Diagnosis is made by examining the rib cage and noting paradoxical movement of a chest wall
segment inward rather than outward during inspiration and outward motion during expiration with
spontaneous breathing. Paradoxical motion/movement is more appreciated when patient will be
examined through palpation of the chest wall and in palpating the patient, note also for pain, deformity
or crepitus and examine bruises or bleeding. Listen and note for bilateral breath sounds as well. Chest
radiographs are performed to confirm the presence of multiple fractures of the ribs, however, chest CT
specifically with 3D reconstruction is a more sensitive technique for confirming rib fractures and other
pulmonary injuries (pulmonary contusions, hemothorax related to chest trauma). Findings in chest CT

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CABILATAZAN, Enjelaine L. BSRT-II May 10, 2020

may help decide on what treatment should be given to the patient. Obtaining a full set of vitals
including an accurate measurement of the respiratory rate and oxygen saturation is also important.

Complete trauma labs and blood gas should be ordered because labs may aid in monitoring the
patient for signs of impending respiratory failure.

Fig. 1 These images are the chest CT scan result of the patient discussed in this case report. Image (A)
shows that the patient has pneumothorax on the left (red arrows) and also revealed lung contusions (white
arrows). Image (B) revealed fractures of the left clavicle and fractures on the third to fifth ribs on the left (red
arrows)

Instead of Repeating this part, you should have just correlated the discussion to the patients diagnostic findings.

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CABILATAZAN, Enjelaine L. BSRT-II May 10, 2020

Fig. 2 This image shows the movement of the chest wall in patient with flail chest.s

D) Treatment

Management of flail chest initially includes maintaining adequate ventilation, fluid management
(must be carefully monitored to avoid pulmonary edema), pain management (intercostal nerve blocks,
oral or IV narcotics, or epidurial anesthesia given as a continuous infusion) and management of the
unstable chest wall. Ventilation of the patient should be maintained with oxygen and noninvasive
ventilation when possible. Invasive mechanical ventilation is used when other methods fail and if
respiratory failure develops, endotracheal intubation and positive-pressure ventilation with positive end-
expiratory pressure may be required for several days. In treating complicated cases, internal pneumatic
stabilization has been used successfully. Surgery essentially uses metallic wires to stabilize the ends of
the fractured rib.

In general, patients who do not require mechanical ventilation have a much better improvement
than those who do.

References:

Tzelepis, G.E(MD) & McCool, D.F.(MD). (2016).The Respiratory and Chest wall diseases: Muray and

Nadel’s Textbook of Respiratory Medicine (6th edition)

Wesson, D.E & CoxJr., C.S. (2012).Thoracic Injuries: Pediatric Surgery (7th edition)

Perera, T.B & King, K.C. (2019). Flail Chest. StatPearls Publishing LLC.

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