Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion

We reviewed 144 consecutive patients with flail chest and/or pulmonary contusion between 1979 and 1984. The purpose was to analyze the factors adversely affecting morbidity and mortality. There were 97 males and 47 females, with an average age of 40 years +/- 18 S.D. (range, 2-83). Seventy-five per cent of the injuries were caused by motor vehicle accidents, with the remainder due to falls (17%), cardiopulmonary resuscitation (4%), altercations (2%), or falling objects (2%). The Injury Severity Score (ISS) averaged 32 +/- 14 S.D. in all survivors versus 60 +/- 14 S.D. in those who died. Eighty-three patients (58%) required mechanical ventilation. Thirty-six patients died (25%). Isolated pulmonary contusion or flail chest had a mortality of 16% each. However, the mortality more than doubled when there was a combined pulmonary contusion and flail chest (42%). More than half of all deaths were directly attributed to central nervous system injuries with another third due to massive hemorrhage. Factors that were associated with a higher morbidity and mortality included severe associated thoracic injuries, a high ISS, the presence of shock, falls from heights, and the combination of pulmonary contusion and flail chest.     

创伤性连枷胸伴肺挫伤的诊疗进展

创伤性连枷胸伴肺挫伤(FC-PC)是胸部急诊创伤中最常见的疾病,病情严重,早期容易出现急性呼吸窘迫综合征(ARDS)、急性呼吸衰竭等症状,后期容易出现肺部感染、脓胸形成等,治疗效果慢、住院时间长、费用高,若不能及时诊断及有效治疗,预后差。该文就近年来国内外在FC-PC的诊断、治疗和临床应用方面做一简要综述。     

Flail chest syndrome and pulmonary contusion.

Controlled mechanical ventilation has been the mainstay of treatment in the flail chest syndrome for more than 20 years, retrospective studies have recently suggested that the technique is unnecessary, and they infer that spontaneous ventilation or intermittent mandatory ventilation are equally effective. The common theme of these investigations is that mechanical ventilation is required only to relieve hypoxemia associated with the underlying contusion. In two cases of flail chest, spontaneous respiratory efforts resulted in complete disruption of the fracture sites and thus prolonged the duration of mechanical ventilation that was required. In severe cases of flail chest syndrome, there is still a need for controlled mechanical ventilation to splint the rib fractures in a position which facilitates union of the fragments.     

The management of flail chest

Flail chest is an uncommon consequence of blunt trauma. It usually occurs in the setting of a high-speed motor vehicle crash and can carry a high morbidity and mortality. The outcome of flail chest injury is a function of associated injuries. Isolated flail chest may be successfully managed with aggressive pulmonary toilet including facemask oxygen, CPAP, and chest physiotherapy. Adequate analgesia is of paramount importance in patient recovery and may contribute to the return of normal respiratory mechanics. Early intubation and mechanical ventilation is paramount in patients with refractory respiratory failure or other serious traumatic injuries. Prolonged mechanical ventilation is associated with the development of pneumonia and a poor outcome. Tracheotomy and frequent flexible bronchoscopy should be considered to provide effective pulmonary toilet. Surgical stabilization is associated with a faster ventilator wean, shorter ICU time, less hospital cost, and recovery of pulmonary function in a select group of patients with flail chest. Open fixation is appropriate in patients who are unable to be weaned from the ventilator secondary to the mechanics of flail chest. Persistent pain, severe chest wall instability, and a progressive decline in pulmonary function testing in a patient with flail chest are also indications for surgical stabilization. Open fixation is also indicated for flail chest when thoracotomy is performed for other concomitant injuries. There is no role for surgical stabilization for patients with severe pulmonary contusion. The underlying lung injury and respiratory failure preclude early ventilator weaning. Supportive therapy and pneumatic stabilization is the recommended approach for this patient subset.     

Flail chest and pulmonary contusion

Flail chest is most often accompanied by a significant underlying pulmonary parenchymal injury and can be a life-threatening thoracic injury. Its management is often complicated by the other injuries it is frequently associated with. Similarly, mortality and morbidity are dictated most often by the associated injuries and findings. Its treatment is complex and should first be one of pain management, judicious fluid resuscitation, and excellent pulmonary toilet. In those patients requiring mechanical ventilatory support, or who require ipsilateral thoracocotomy, rib stabilization may be considered depending on a host of potentially conflicting indications and contraindications. At the end of this section are listed the current major recommendations and their levels of evidence.     

37例严重连枷胸合并肺挫伤患者的胸部护板固定治疗分析

目的探讨胸部护板联合机械通气治疗连枷胸合并肺挫伤的疗效。方法回顾性分析2005-02～2010-02本院收治的37例严重连枷胸合并肺挫伤患者,37例患者分为胸部护板组(20例)和对照组(17例)。对2组患者治疗24h后的酸碱度(pH值)、氧分压(PaO2)、二氧化碳分压(PaCO2)、氧饱和度(SaO2%)、机械通气时间以及疼痛指数(数字疼痛分级法NVS)进行比较分析。结果 2组比较pH值、PaO2、PaCO2、SaO2%及机械通气时间有差异(P0.05);2组疼痛指数比较差异有统计学意义(P0.01)。结论胸部护板联合机械通气在治疗连枷胸合并肺损伤患者中能明显改善病情,减轻患者疼痛。     

A frequent fiber-scopic bronchial lavege for the case of bilateral sever pulmonary contusion with flail chest

A 26-year-old man was injured in the traffic accident. He had complicated chest trauma. He came to our hospital by ambulance immediately after rescued from crashed his automobile. He had severe pulmonary contusion with frail chest, pulmonary laceration, tension hemopneumothorax, and hypovolemic shock, and air embolism of the brain. He was managed with fiber-optic bronchoscopy under mechanical ventilation and chest drainage. Frequent broncho-scopic bronchial lavage of respiratory tract with thrombin and adrenaline solution was helpful to prevent anoxia due to complicated chest injury. He developed acute bacterial empyema and multiple organ failure due to septic shock during intensive care for trauma. However, he underwent surgical treatment for empyema and fully returned to his work after 6 months after his critical accident.     

Pathophysiology and management of the flail chest

Flail chest occurs when a series of adjacent ribs are fractured in at least 2 places, anteriorly and posteriorly. This section of the chest wall becomes unstable and it moves inwards during spontaneous inspiration. The physiological impact of a flail chest depends on multiple factors, including the size of the flail segment, the intrathoracic pressure generated during spontaneous ventilation, and the associated damage to the lung and chest wall. Treatment varies with the severity of the physiologic impairment attributable to the flail segment itself. Immediate surgical fixation may decrease morbidity, but conservative treatment with positive pressure ventilation is preferred when multiple injuries to the intrathoracic organs are present.     

Technique for the management of anterior flail chest.

A technique for the management of anterior flail chest consisting of osteosynthesis and the positioning of two long Kirschner wires behind the sternum in the form of a St Andrew's cross is described. The procedure is easy to perform, the patient is ambulant early, and the results are good.     

Blood gas analysis in management of flail chest injuries

Six cases of flail chest injury were studied for changes in blood gases and acid-base status before and during respiratory management. Metabolic acidosis and mild to severe hypoxemia were found in most patients with flail chest at the time of admission, and there was a relationship between manifestation of paradoxical respiration and hypercarbia. Serial blood gas determinations are extremely important in assessment of the adequacy of the therapy, particularly in management of flail chest with continuous IPPB therapy.     

Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status

Through a prospective randomized comparative study, treatment of flail chest by a non-surgical method of packing, strapping, and mechanical ventilation vs. surgical fixation were compared. After management, stability of the chest wall occurred in 85% of the patients in the surgical group. Forty-five percent of patients in this group required ventilatory support after fixation for an average of 2 days. Whereas in the conservative group, stability occurred in 50% of their patients, and 35% of patients required ventilatory support for an average of 12 days. Chest wall deformity in the form of stove-in chest and crowding of ribs was still obvious in 9 patients among the conservatively treated group, compared to only one patient who developed chest wall deformity in the surgically treated group. The pulmonary functions tested two months after management indicated that in the surgical group the patients had a significantly less restrictive pattern. Thus, surgical fixation of a flail segment is a method of great value in the treatment of flail chest, in which stability is achieved without deformity of the chest wall and patients have less restrictive impairment of pulmonary functions.     

The treatment of flail chest injury.

Flail chest injuries are traditionally managed by long-term artificial ventilation, which in itself is hazardous and expensive. A more conservative therapeutic regime is described, and the results of this regime are compared with those following the previous traditional regime used in the Respiratory Unit, Royal Brisbane Hospital. The place of artificial ventilation in relation to spontaneous ventilation is redefined in the context of this new regime.     

Surgical stabilization of traumatic flail chest.

Since 1970 we have stabilized the ribs to correct paradoxical movement of the chest wall in chest injuries, using an original technique, in order to avoid as far as possible the need for long-term chest wall stabilization by intermittent positive pressure respiration (IPPR). The technical details of surgical stabilization are described, and the different types of stainless steel struts are shown. Type I was originally used either as an intramedullary nail or as an external brace. Types II and III were designed for external fixation of the strut to the rib. Treatment of 29 patients with severe flail chest, classified into four groups is shown: group I was treated by IPPR, group II by IPPR plus surgical stabilization, group III by surgical stabilization only, and group IV by surgical stabilization after exploratory thoracotomy. The clinical results are discussed. We conclude that surgical stabilization of the paradoxial movement of the chest wall can avoid the use of the respirator or at least reduce the interval of IPPR to a short period during the initial recovery from trauma. Using type III struts, we have obtained stabilization of the flail chest in all cases even in patients with severe anterior paradoxical movement. The patients'' tolerance of surgical stainless steel struts was good.     

Fractured sternum with flail chest and posttraumatic pulmonary insufficiency syndrome. Report of 4 patients

The case histories of 4 patients who sustained sternal fractures with flail chest and pulmonary insufficiency are reported. Prompt open reduction and stabilization of the fractured sternum and continuous monitoring of cardiopulmonary function are necessary to prevent or control posttraumatic pulmonary insufficiency syndrome, which is the major cause of death in these patients.     

The management of flail chest injury: factors affecting outcome

The records of 57 patients presenting with flail chest injury from 1981 through 1987 were reviewed to determine factors affecting morbidity and mortality. Fifteen patients (26%) had 8+ rib fractures with a unilateral flail and seven (12%) had multiple rib fractures with a bilateral flail. Thirty-two (56%) had moderate-severe pulmonary contusions and 44 (77%) required chest tubes for hemo-pneumothorax. Ventilatory assistance was used in 36 (63%). The major factors determining the need for ventilatory assistance were: an ISS greater than or equal to 23, blood transfusions in the first 24 hours, moderate-severe associated injuries (fractures, head injuries or truncal organs requiring operation), and shock on admission (p less than 0.001). An adverse outcome occurred in 15 (28%); nine required ventilatory assistance greater than or equal to 14 days and six died of sepsis with pneumonia. The main factors associated with an adverse outcome were: an ISS greater than or equal to 31 (p less than 0.001), moderate-severe associated injuries (p less than 0.001), and blood transfusions (p less than 0.005). Although the primary determinants of an adverse outcome were the associated injuries and blood loss, a bilateral flail (p less than 0.01) and age greater than or equal to 50 years (p less than 0.02) were contributing factors.