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DEPARTMENT: BARCHELORS OF SCIENCE IN NURSING

NAIROBI CAMPUS

NAME: EVERLINE MUKHWANA ABWAO

REG NO: BSN-1-3421-3421-3/2019

20/03/2019

MODE OF STUDY: DISTANCE LEARNING

CRITICAL CARE CASE STUDY

DIAGNOSIS: CHEST INJURY – FLIAL CHEST

M.P. SHAH HOSPITAL

CRITICAL CARE UNIT

LECTURER: DR. AGNES MUTINDA

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Abbreviation and acronyms

CCN -Critical Care Nurse.

C.C.U -Critical Care Unit.

BIPAP -Bi-phasic Positive Airway Pressure

SIMV -Synchronized Intermittent Mandatory Ventilation

CPAP -Continuous Positive Airway Pressure.

IPPV -Intermittent Positive Pressure Ventilation

GCS -Glasgow coma scale

PaO2 -Partial Pressure of oxygen

PCO2 - Partial Pressure of carbon dioxide

SPO2 - Saturation of oxygen.

Hb - Haemoglobin

RBS - Random blood sugar.

WBC -White blood cell

RBC - Red blood cell.

C.V.C - Central venous catheter.

HCT - Haematocnt

M/C/S -Microscopy culture and sensitivity

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Na+ -Sodium

RR -Respiration rate.

K+ -Potassium.

BE -Base excess.

HCO3 -Bicarbonates.

CNS -Central Nervous System.

RTA -Road Traffic Accident

ABGA’S -Arterial Blood Gases analysis.

CT -Computed Tonogtaphy

BP -Blood pressure

Mm/hg -Millimetres of mercury.

g/dl -Grams per deciliters.

Mmo/l -Moles per litres

C/min -Counts per Minute.

b/min -boats per minute.

Kpa -Kilopascals.
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INTRODUCTION

The case study was carried out at M.P. Shah Hospital critical care unit. The hospital is Located in

Parklands Area in Nairobi County, M.P. Shah Hospital is a modern 210-bed facility which is

home to highly skilled and experienced specialists and professional medical staff. MP Shah

Hospital has been recognized as a national referral facility with ISO 9001:2015 quality

management certification. It is affiliated to COSECSA (College of Surgeons of East Central and

Southern Africa), an independent body that fosters postgraduate education in surgery and

provides surgical training.

VISION

The hospital’s vision is “Determination and selfless concern for the well-being of the

community”.

Mission

The mission is to provide Patient centered care driven by values of the social service league

Description of placement

M.P Shah’s Critical Care Unit is located at the ground floor proximal to the main entrance. It has

8 rooms where 2 are designated for isolation cases. It is equipped with 8 ventilator machines and

10 monitors. The CCU has a water system flow for dialysis patients and a total of 21 CCU

trained nurses inclusive of the nurse in charge and her deputy. It has 5 support staff and 2

intensivists who work on call basis in collaboration with the medical staff who are always in

bedside-working shifts of 12 hours. It is also a learning unit to healthcare students from various

institutions. The most common cases are chronic pulmonary diseases, kidney and chest injuries.
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BRIEF DESCRIPTION OF MY CLIENT

The patient of this study is male, 35 years of age who was admitted on 23.03.2019 with a

diagnosis of Flial-chest injury due to Road traffic accident (RTA). He was brought to the hospital

by the police and a good samaritan who rescued him from his car after the accident. They arrived

at the hospital at 2.40pm.

THE CASE

Name: L.M.N

Age: 35 years

Sex: Male

Nationality: Kenyan

Religion: Christian

Residence: Allsops

Occupation: Businessman

Next of Kin: P.D

Relationship: Wife

Ward: CCU

D.O.A: 23.03.2019

Diagnosis: Flail chest 2◦ RTA

Chie complains

Patient had frank bleeding from the nose and difficulty in breathing with low levels of

consciousness.
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History of present illness

Patients was involved in an accident at Thika road on 23th march 2019 where he was hit by an

over speeding personal car in attempt to change lanes on the road on his way back home from

work. He was rushed to Hospital by good Samaritans as he had sustained multiple traumas.

Past medical and surgical History

L.M.N had never been hospitalized or undergone any operations before. He had no history of

allergies to food and drugs but only minor ailment which were treated in out – patients

departments.

Family social history

L.M.N is 2nd born in a family of 4 siblings – 2 boys 2 girls all siblings alive and well. His parents

live at Narok County. Nobody in the family has any chronic illness like diabetes, hypertension or

chronic respiratory condition

Social - Economic History

His father and mothers are both secondary school teachers in Narok county schools. His elder

brother is also a teacher in Nairobi – Embakasi and the two sisters are still in College at Narok

County.
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PHYSICAL EXAMINATION

On physical examination the following findings were noted.

a. Central Nervous System: Patient had low conscious levels opening his eyes, with pupil

sizes 2mm both reactive to light.

His total GCS (Glasgow coma scale) was 9/15 Eye opening 5, verbal response 2, monitor

response 2.

b. Cardiovascular System: patient was connected to a continuous cardiac monitor and had

sinus tachycardia rhythm, Bp. 96/60 mmHg, pulse 90b/m cardiac sounds S¹ and S² both

normal and well heard. Peripheral pulses were all felt, capillary refill & 3 seconds in all

extremities Hb.12.2.g/dl.

c. Respiratory System: Patient was put on oxygen via Non – rebreathe mask, has

spontaneous breathing 28c/min. chest shape was barrel with paradoxical movements

noted media sternum shifting to the right side , asymmetrical chest expansion, abnormal

tactile and vocal fremitus with crepitation heard on auscultation SPO² 96% with minimal

secretions.

d. Gastro- intestinal System: Abdomen was tender and distended and painful especially on

the Splenic region, bowel sounds well heard.

e. Skin and Muscular skeletal System: Patient had intact skin; body temperature of 36◦c

skin was a bit clammy though warm. His upper and lower extremities were very weak.

Plan was prepare for theatre for splenic repair, intubation, Foley catheter insertion,

Nasogastric tube insertion, ABGA’s, Monitor closely vitals and input and output.
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PROCEDURES AND MEDICATION

Several investigations were done on patient L.M.N. Some of the investigations include;

 Blood gases analysis < arterial> - This was done daily for the entire stay in c.c.u.

 Blood sugars - This was done on daily basis or when necessary

 Urea electrolytes and creatinine

 Coagulation tests.

 Liver function tests.

 Total blood count.

 Tracheal aspirates – This was done weekly and whenever necessary.

 Stool for culture and sensitivity.

 Chest X- ray. – This was done on admission.

 Abdominal computed tonographic scan - This was done on admission.

Blood gas results

Investigations Normal Limits

PH - 7.275 (7.35 – 7.45)

PCo2 – 5.05.Kpa (4.27 – 6.00) Kpa

PO2 – 9.86 Kpa (10.0 – 13.3) Kpa

HCo³ - 21.03 (22.0 – 27) mmol/L

BE - ̄ 3.5 (̄2 - +2)

HCT – 55% (34% - 52%)

HB. - 10.4g/dl (12 - 18) g/dl

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SPO² -96% (95 – 100) %

Na ˖ - 135.5 mmol/L (135 0 145) mmol/L

K˖ - 3.55 mmol/L (3.5 - 5) mmol/L

Glucose – 6.68 mmol/L (3.5 – 8.3) mmol/L

History and management of patient.

Patient was prepared and taken to theatre for emergency laparotomy (spleen repairment) on 23rd March 2019 at

3.00p.m.

23/03/2019.

At 3.30p.m warded back in C.C.U. intubated C.V.C and chest tube in situ. Nasogastric tube inserted, put on

mechanical ventilation IPPV under sedation. Feeding commenced after nutritional review fresubin 83m/s/hr,

blood transfusion commenced.

Nursed in head elevation 30◦ degrees up. Input and output measuring of all drains. Other nursing care

commenced; bed bath, feeding, pressure area care, drug administration, oral and invasive site care,

psychological care, vital signs monitoring and suctioning 4 hourly/ PRN. Plan .Antibiotic coverage, Analgestic

treatment and ulcer prophylaxis. BP 100/60 mmHg pulse 82bpm RR 24c/min Temperature 36◦c commenced

on 1v meropenem, iv zantac , IM Morphine 1mg/l 6 hourly, iv perfalgan 1gm 8 hourly.

24/03/2019.

Patient was reviewed by C.C.U doctor arterial blood gases as follows

PH ̄ 7.24, PCO² - 5kpa. PO² 16.6 kpa, HCO³ 18.8 mmo/l BE – 3.8, Na˖136m/l K˖ 3.5 mmo/l Hb – 6.4g/dl,

RBS 5.9 mmo/l. Metabolic acidosis uncompensated with Aneamia GCS 10т/15.

Plan: Transfuse 2 pints of whole blood, grouping and cross matching intravenous fluids. Normal saline with iv

5% Dextrose alternate and ventilation mode changed to SIMV Tidal volume 500m/s , Fraction of inspired

oxygen 60% RR. 14 dm/n PEEP 5.12.30 p.m. First pint of blood transfusion commenced and ended up at 3.20
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p.m then second pint commenced at 4 p.m ended up at 8 p.m with no adverse reaction. Then put on intravenous

fluids and continuous feeding at 83m/s/hr.

25/03/2019.

Patient reviewed by C.C.U doctors team, commence on clexane 40mg OD, sub – cutaneously, sedation with

dormicum to commence and continued with other previous medication and SIMV mode of mechanical

ventilation for physiotherapy and occupational therapy.

Plan: Liver function, coagulation and Electrolytes tests. Arterial blood gases within normal limits and Hb

11.88g/dl thus put on oral heamatinics syrup ranferon 10m/s 8 hourly.

26/03/2019

Patient still on mechanical ventilation SIMV mode, Mechanical, nursing care and physiotherapy continued.

GCS IOT/15 good input output chest drain active, passing loose stool doctor ordered for culture and

sensitivity. Tests previously done; Liver function test, urea and electrolytes test, coagulation test and arterial

blood gases all within normal limits. Hb 12.4g/dl.

27/03/2019.

Review by doctors’ team, chest drain reviewed and site well secured. Culture and sensitivity test for stool was

negative plan; continue medical, nursing care and physiotherapy. Nutrition review by unit nutrionist added

mala 200m/s 8 hourly. GCS 10т/15.

28/03/2019.

Patient L.M.N getting continued medical and nursing care, on doctors review during ward round; has good

bilateral air entry, hemodynamic within normal ranges. Put on CPAP. (Continuous positive Airway pressure

mode) parameters as follows; fraction of inspired oxygen 35% PEEP 8 other settings maintained. GCS 10т/15.

Plan, wean off sedation immediately, for thermo vent if prognosis is satisfactory.

29/03/2019.
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Patient showing great improvement, daily nursing medical care continued GCS 10т/15 Normal vital signs and

arterial blood gases. Nutritional, physiotherapy and skin care done daily.

30/3/2019.

Reviewed during doctors ward round, put on thermo vent oxygen 3 litres, chest is clear and GCS 10т/15. SPO²

98%.

31/03/2019.

Patient L.M.N improving remarkably, able to sit on the bed and having good input and output, GCS 10т/15 on

Daily physiotherapy, nursing, medical, and psychological care. Extubated, physiotherapy and nebulization

done put on simple face mask with oxygen 1litre SPO² 100%. Able to talk and well oriented post extubation

heamodynamics within normal ranges GCS 14/15.

Plan observe and for possible discharge to the ward.

1/04/2019.

Patient L.M.N discharged to ward 4B for continuous monitoring and evaluation patient was observed for a

week the discharge summary was prepared to be discharged home.

2/04/2019. Patient was discharged home through surgical clinic and went home, was given appointment every

once a week in the hospital.

Nursing tools used in care of patient L.M.N.

a. Nursing Care cardex; to document nursing notes.

b. Nursing care plan for every day care.

c. Critical care unit observation charts.

d. Infection preventive and control charts.

e. Neurological status chart.

injuries and is likely the most common serious injury to the thorax seen by clinicians.
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Specific procedures

a. Intubation and mechanical ventilation, to provide optimum ventilation, gaseous exchange and

prevent respiratory failure. Since patient had chest injury and resulted in paradoxical movement and

respiratory distress.

b. Nasogastric tube insertion and feeding to maintain good nutritional status since patient had general

body weakness and poor G.C.S.

c. Cardiovascular catheter insertion: Facilitate drug administration, intravenous fluid administration,

parenteral feeding and measurement of central venous pressure to check hydration status.

d. Chest tube insertion under water seal drainage; to monitor status of the draining output,

fluctuations, Amount, colour in order to take immediate actions incase of any abnormalities.

e. Close observation using cardiac monitor; to rule out any deviation from normal limits, and monitor

cardiovascular changes due to autonomic dysfunction.

f. Total nursing care done since patient was bedridden, includes; feeding and elimination care,

pressure area care, oral and CVC site care, skin care, suctioning, monitoring input, output,

psychological care and eye care.

Nursing care was planned and evaluated daily.

Family involvement.

Patient L.M.N parents and siblings were deeply involved in his care by ensuring all of L.M.N’s needs were

met and daily psychological care. This includes, buying drugs which were not available in the hospital,

buying him feeds like mala and also petroleum jelly for skin care.
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Team co-ordination

There was good collaboration in all the health workers in C.C.U and ensured optimal patient care.

Doctors; reviewed him daily adjusting medications and also surgical care/ procedures like C.V.C insertion,

spleen repair, chest tube insertion and intubation.

Nurses; Played a big role by giving optimal care to meet all patient needs and acting as patients advocates.

Physiotherapists; Attended to him daily ensuring airway patency and providing continuous range of

motion exercises.

Nutritionists; Met patient daily caloric needs improving nutritional status.

Laboratory technologists; carried lab request according especially on arterial blood gases analysis, RBS,

Hb on daily basis.

Counselor; Catered for both patients’ and family psychological status.

Support staff; Ensured clean and conducive environment for patient, health care workers and relatives.

Follow up care.

Patient L.M.N was discharged from C.C.U to ward 4B for further management and continuous observation.

There after was discharged home after a week through surgical outpatient’s clinic to be coming once every

week.
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DRUG INDEX

Clexane

Classifications: Anticoagulant.

Mode of action: stops new clots formations and stops further growth of existing clots.

Indications: Given to bed ridden patients’ prophylactic ally.

Given to patients with embolism due to a thrombus.

Given to patients with hypercoagubility defects.

Contraindication: Patients with bL.M.Nding tendencies.

Side effects: BL.M.Nding, severe headaches, back pain, CI bL.M.Nding bruises and tender swollen

areas.

Zantac/ Ranitidine

Classification: Histamine 2 blockers.

Mode of action: It works by reducing amount of acid produced by stomach and intestines.

Treats zollinger Ellison syndrome GERD.

Side Effects: Chest pain, fever, easy bruising, bL.M.Nding, bracycardia/ tachycardia, vision problems, sore

throat, headaches, appetite loss.

Diazepam

Classification: Benzodiazepines.

Indication: Treats anxiety, acute alcoholic withdrawal, seizures, muscle spasm relief.

Mode of action: Blocking neuromuscular receptors.

Side effects: Respiratory distress.

Contraindications: respiratory failure, severe respiratory distress.

Paracetamol (Acetaminophen).
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Classification: non- oploid analgesia

Indication: Mild to moderate pain, pyrexia.

Mode of action: Inhibition of prostraglandins synthesis particularly clo oxygenase 2.

Side effects: Hepatotoxicity.

Contraindications: liver failure

Morphine Sulphate.

Classification: Opioids analgesic

Mode of action: Vasolidilation.

Relieves pain.

Indication: Trauma, post surgery, celebral vascular accident, coronary artery disease.

Contraindication: Pancreatitis (acute and severe).

Side effects: vasospasms.

Ranferon

Classification: Heamatinic.

Mode of action: Provision of iron (Fe²˖) ions.

Indications: Anaemia due to different etiologies like dietary, blood loss.

Contraindication: Polycytheamia verria.

Side effects: toxicity.

Meropenem

Classification: Antibiotic. < Carbapenem>

Mode of action: Bacteriocidal. (Slow bacterial growth and reproduction).

Indication: Any systemic infection.

Contraindication: Hypersensitivities, liver failure.

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Side effects: Allergic reactions.

Nursing care plan

NURSING CARE PLAN  

Nursing Expected Nursing
Assessment diagnosis outcomes interventions Rationale Evaluation
Use of Altered gaseous The patient will Patient was To improve Optimum respiratory
accessory exchange have improved intubated and oxygenetatio function obtained after
muscles and related to respiratory sedated then n and ease intubation and
hyperventilatio paradoxical function. commenced on work of commencing mechanical
n. High PCO² chest mechanical breathing. ventilation. Repeat of
and low PO² movements and ventilation IPPV To enhance blood gas analysis show
on arterial impending mode on first 24 good increasing PO² and
blood gas respiratory hours of admission respiratory decreasing PCO² both
analysis failure as and dead space function. within normal limits.
evidenced by increased.
use of accessory
muscles and
CO² retention.
Adventitious Ineffective The patient will Proper suctioning To clear the Good bilateral chest
breathe sounds airway have a patent and pre- airway and expansion and air entry
heard on deanence airway and oxygenation 4 allay in the first 2 hours. Chest
auscultation on related to poor clear lung hourly or PRN breathing x ray show no mucoid
basal lung chest expansion fields. position in semi discomfort. accumulation and clear
fields and injury to fowlers position to lung fields.
<crepitations> lung increase chest
and chest x- panenchyma as expansion.
ray showing evidenced by
bronchorrhoea. crepitations on
auscultations
and areas of
bronchorrhoea
on chest x ray.
Shallow Impained Patient will Close monitoring To detect Proper respiratory
breathes with breathing have improved of respiratory abnormality function achieved SPO²
respiratory pattern related breathing and mechanism like in parameters range (95-100) %
distress. to poor lung respiratory SPO² and the and intervene and normal respiratory
Hyperventilati compliance and function. respiratory rate. early and to rates.
on and low increased lung establish
SPO² resistance proper
evidenced by respiratory
shallow function.
breathes and
low SPO².
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Elevate heart Altered comfort To keep patient Patient To allay Patient becomes calm
rate above 100 related to pain comfortable and commenced on agitation and and restful heart rate
beats / minute manifested by stabilize the sedatives and ventilation lowers but within normal
patient is patient being heart beat. analgesics. dysynchrony limits.
restless and restless, Dorminicum/ and block
agitated. Agitated and morphine infusion pain receptor
increase heart at 5m/s hour. site and
rate. prevent
vasospasms.
Patient looks Fear and To allay anxiety Engaging patient Counseling Patient and family
irritable and anxiety related and decrease in his care, session with members are able to cope
terrified. to fear of fear. explaining every unit and adjust to the
Relatives seem impencting procedure and its counselor to situation.
to despair. doom. purpose. relieve
anxiety and
demystify
believes /
myths on the
condition an
I.C.U stay.
Knowledge Patient and Explaining to To provide Patient and relatives
Relatives and deficit related to Relatives to relatives and adequate calmness and co-
Patient ask too disease process have detailed patients about the knowledge of operation obtained.
many as evidenced by knowledge of disease process, its the
questions patient asking the disease and management and condition.
about the too many possible possible outcomes.
condition and questions. outcomes.
prognosis.

LITERATURE REVIEW
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Definition

Chest wall injury is an extremely common following blunt trauma. It varies in severity

from minor bruising or an isolated rib fracture to severe crush injuries of both hemi

thoraces leading to respiratory compromise.

While many chest injuries will require no specific therapy, they may be indicators of more

significant underlying trauma. Multiple rib fractures will often be associated with an underlying

pulmonary contusion, which may not be immediately apparent on an initial chest X-ray.

Fractures of the lower ribs may be associated with diaphragmatic tears and spleen or liver

injuries. Injuries to upper ribs are less commonly associated with injuries to adjacent great

vessels. This is especially true of a first rib fracture, which requires a significant amount of force

to break and indicates a major energy transfer.

A fracture of the first rib should prompt a careful search for other injuries. Note also that the rib

cage and sternum provide a significant amount of stability to the thoracic spine. Severe

disruption of this 'fourth column' may convert what would otherwise be a stable thoracic spine

fracture into an unstable one.

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Flail Chest

A flail chest occurs when a segment of the thoracic cage is separated from the rest of the chest

wall. This is usually defined as at least two fractures per rib (producing a free segment), in at

least two ribs. A segment of the chest wall that is flail is unable to contribute to lung expansion.

Large flail segments will involve a much greater proportion of the chest wall and may extend

bilaterally or involve the sternum. In these cases the disruption of normal pulmonary mechanics

may be large enough to require mechanical ventilation.

R flail chest Right rib fractures.

The main significance of a flail chest however is that it indicates the presence of an underlying

pulmonary contusion. In most cases it is the severity and extent of the lung injury that determines

the clinical course and requirement for mechanical ventilation. Thus the management of flail

chest consists of standard management of the rib fractures and of the pulmonary contusions

underneath.
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MANAGEMENT

Management of chest wall injury is directed towards protecting the underlying lung and allowing

adequate oxygenation, ventilation and pulmonary toilet. This strategy is aimed at preventing the

development of pneumonia, which is the most common complication of chest wall injury.

Note that while a young fit patient will easily manage one or two rib fractures with simple

analgesia, the same injury in an elderly patient is regarded as major and will frequently lead to

pneumonia and respiratory failure if not appropriately managed (and even then).

Oxygenation

All patients should initially be placed on 100% oxygen via a non-rebreathe facemask and

consider intubation.

Analgesia

Analgesia is the mainstay of therapy for rib fractures. While strapping the chest to splint rib

fractures may seem like a good idea, it impedes chest wall movement and prevents adequate

inspiration and clearance of secretions. Opioid analgesics are useful, but when used as the sole

analgesic agent may require such high doses that they produce respiratory depression - especially

in the elderly.

Patient controlled administration of an opioid infusion (PCA) is the best method for cooperative

patients. The addition of a non-steroidal anti-inflammatory agent may provide adequate relief,

but these should be withheld until other injuries have been excluded (eg. traumatic brain injury)

and used with caution in the elderly.

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Undoubtedly the best analgesia for a severe chest wall injury is a continuous epidural infusion of

a local anaesthetic agent (+/- an opioid). This provides complete analgesia allowing normal

inspiration and coughing without the risks of respiratory depression. Epidurals may be placed in

the thoracic or high-lumbar positions.

Other methods of local anaesthetic administration are available, but are poor in comparison to an

epidural. For one or two isolated rib fractures, posterior rib blocks may be appropriate. Local

anaesthetic is infiltrated around the intercostals nerve posteriorly. These blocks will last 4-24

hours and will then have to be repeated. Where a chest tube is present, some practitioners

advocate instilling a local anaesthetic solution into the pleural splace. However the volume

needed is large, the results very variable and local anaesthetic toxicity due to rapid pleural

absorptionpossibility.

Intubation & Ventilation

Intubation and mechanical ventilation is rarely indicated for chest wall injury alone. Where

ventilation is necessary it is usually for hypoxia due to underlying pulmonary contusions.

Positive pressure ventilation may be required for severe chest wall instability resulting in

inadequate spontaneous ventilation.

Intubation and ventilation may be required when anesthesia is necessary to provide immediate

and adequate analgesia and allow further assessment and management.

Ventilation is usually necessary only until the resolution of the pulmonary contusion. Healing

and stabilization of rib fractures is rarely the limiting step in weaning from mechanical

ventilation, except in the most severe chest injuries.

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Chest tube insertion

Patients with rib fractures who receive positive pressure ventilation are at an increased risk of

developing a pneumothorax or tension pneumothorax due to laceration of the lung by the sharp

fracture end.

Many authors recommend placement of a prophylactic chest tube for all patients with rib

fractures who receive mechanical ventilation. This practice varies depending on the presence of

other injuries, monitoring environment and available resources. For example, the patient with

isolated chest injuries with continuous cardiorespiratory monitoring in an intensive care unit can

probably be observed without a chest tube. In contrast, in a patient anaesthetized for prolonged

surgery, placement of a prophylactic chest tube may be more appropriate. Especially where the

signs of a tension pneumothorax may be mistaken for signs of hemorrhagic shock.

Rib fracture fixation

The popularity of rib fracture fixation has waxed and waned over the past 5 decades. External

fixation and stabilization was common for large chest wall injuries prior to the development of

tracheal intubation and mechanical ventilation.

Positive pressure ventilation essentially provides an 'internal stabilization' to the thoracic cage as

well as improving oxygenation and ventilation for the management of pulmonary contusion.

Hence it has essentially replaced fracture fixation over the past twenty years. In the last few

years however a few studies have suggested that some groups of patients (as yet unidentified)

may benefit from early fracture fixation, allowing earlier weaning from mechanical ventilation

and reducing acute complications and chronic chest wall pain.

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Radiological Examination

a. Chest X-ray

The anterior-posterior chest radiograph will identify most significant chest wall injuries, but will

not identify all rib fractures. Lateral or anterior rib fractures will often be missed on the initial

plain film. However, since the management of rib fractures is determined by their clinical

significance rather than by their number or position, dedicated rib views are never indicated.

 For adult blunt trauma patients, a haemothorax, pneumothorax or pulmonary contusion

seen on chest X-ray will almost always be associated with a rib fractures, whether or not

identified clinically or by X-ray. In pediatric patients the ribs are more pliable and less

likely to fracture, although there will still be significant contusion of chest wall

structures.

Diagram illustrating flail segment

R flail segment R flail segment

L rib fractures close-up

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b. Computed Tomography

Computed tomography provides very little further clinical information and is not indicated for

the initial evaluation of chest wall injuries.

2.6 Complications

 Respiratory failure

 Cardiac failure

 Hypovolemic shock

N/B: what is a paradoxical movement? Pulmonary contusions are commonly associated with

flail chest and that can lead to respiratory failure. This is due to the paradoxical motions of the

chest wall from the fragments interrupting normal breathing and chest movement.

When a patient has a flail chest there is paradoxical chest wall movement what is the effect of

this on the lungs during inspiration?

Falls account for 14% of flail chest injuries. This typically occurs when three or more adjacent

ribs are fractured in two or more places, allowing that segment of the thoracic wall to displace

and move independently of the rest of the chest wall.

Signs and symptoms

Two of the major symptoms of flail chest are chest pain and dyspnea

Others include: mediastina shift to affected site , use of accessory muscles ,increased work of

breathing, hypoxia and cyanosis among others.

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Pathophysiology

The characteristic paradoxical motion of the flail segment occurs due to pressure changes

associated with respiration that the rib cage normally resists:

 During normal inspiration, the diaphragm contracts and intercostal muscles pull the rib

cage out. Pressure in the thorax decreases below atmospheric pressure, and air rushes in

through the trachea. The flail segment will be pulled in with the decrease in pressure

while the rest of the rib cage expands.

 During normal expiration, the diaphragm and intercostal muscles relax increasing internal

pressure, allowing the abdominal organs to push air upwards and out of the thorax.

However, a flail segment will also be pushed out while the rest of the rib cage contracts.

The constant motion of the ribs in the flail segment at the site of the fracture is extremely painful,

and, untreated, the sharp broken edges of the ribs are likely to eventually puncture the pleural sac

and lung, possibly causing a pneumothorax. The concern about "mediastinal flutter" (the shift of

the mediastinum with paradoxical diaphragm movement) does not appear to be merited.

Pulmonary contusions are commonly associated with flail chest and that can lead to respiratory

failure. This is due to the paradoxical motions of the chest wall from the fragments interrupting

normal breathing and chest movement.

Typical paradoxical motion is associated with stiff lungs, which requires extra work for normal

breathing, and increased lung resistance, which makes air flow difficult.
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The respiratory failure from the flail chest requires mechanical ventilation and a longer stay in an

intensive care unit. It is the damage to the lungs from the flail segments that are life-threatening.

Prevalence

Approximately 1 out of 13patientsadmitted to the hospital with fracturedribs are found to have

flail chest (Fulton &Peter, 2009).

Results

The death rate of patients with flail chest depends on the severity of their condition ranging from

Causes

The most common reason for flail chest injuries are vehicle accidents, which account for 76% of

flail chest injuries (Fulton &Peter, 200).

Another main cause of flail chest injuries results from falling which is mainly elderly related.

The elderly are more impacted by the falls as a result of their weak and frail bones, unlike their

younger counterparts who can fall without being impacted as severely. Falls account for 14% of

flail chest injuries.

Rollover and crushing injuries most commonly break ribs at only one point– for flail chest to

occur a significant impact is required, breaking the ribs in two or more places. This can be caused

by a significant fall, car accident or other forceful accidents. In the elderly, it can be caused by

deterioration of bone, although rare.

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In children, the majority of flail chest injuries can be a result of the common blunt force traumas

or metabolic bone diseases, one known as ontogenesis imperfecta.

See the image below:

Image depicting multiple fractures of the left upper chest wall

The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along

the mid lateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines)

may result.

Multiple care patterns and treatment modalities have emerged, many based on anecdotal clinical

observation and evidence. Within the last 20 years, more rigorous scientific methods have been

applied to the problem of flail chest, in both the clinical setting and laboratory. More advanced

radiologic work-up with multislice computed tomography (MSCT) scanners is increasing the

frequency of diagnosis of this problem. This article reviews the most salient data of the recent

literature and discusses some of the diagnostic and treatment options that are now available in

the treatment of flail chest.

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Severe blunt injury to the chest continues to be one of the leading causes of morbidity and

mortality in both young and old trauma victims .Flail chest is one of the worst subset of these

Recommendations.

The hospital care given to patient L.M.N was good and yielded good results but some considerations are

needed for improvement; and for optimal care.

Doctors ward round should to be done early enough in order to attain new adjustments on time and avoid

postponing many procedures to be done.

Critique

Flail chest is a very fatal and critical condition. It’s said that most patients with flail chest end up with

respiratory failure and die. However the care given to patient L.M.N was prompt and excellent.

Conclusion

He recovered well without any complications due to the good team work among health workers in the unit.

This case study enabled me to learn more about chest injuries in this case heamothorax and flail chest and

dispute the belief that almost all patients with this condition die.
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References

1. JayleJayle, C. P., Allain, G., Ingrand, P., Laksiri, L., Bonnin, E., Hajj-Chahine, J., ... &

Corbi, P. (2015). Flail chest in polytraumatized patients: surgical fixation using Stracos

reduces ventilator time and hospital stay. BioMed research international, 2015.

2. Schulz-Drost, S., Grupp, S., Pachowsky, M., Oppel, P., Krinner, S., Mauerer, A., ... &

Langenbach, A. (2017). Stabilization of flail chest injuries: minimized approach

techniques to treat the core of instability. European Journal of Trauma and Emergency

Surgery, 43(2), 169-178.

3. Schuurmans, J., Goslings, J. C., & Schepers, T. (2017). Operative management versus

non-operative management of rib fractures in flail chest injuries: a systematic

review. European Journal of Trauma and Emergency Surgery, 43(2), 163-168.

4. Zhang, Y., Tang, X., Xie, H., & Wang, R. L. (2015). Comparison of surgical fixation and

nonsurgical management of flail chest and pulmonary contusion. The American journal

of emergency medicine, 33(7), 937-940.

5. Xu, J. Q., Qiu, P. L., Yu, R. G., Gong, S. R., Ye, Y., & Shang, X. L. (2015). Better short-

term efficacy of treating severe flail chest with internal fixation surgery compared with

conservative treatments. European journal of medical research, 20(1), 55.