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Old 04-19-2008, 06:10 PM   #1
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Treatment for flail chest


Just a quick question for everyone (I am also going to do my own research to see what I can find out on my own).

What is currently being taught to EMTs regarding the management of a flail chest?

I ask because we held a physical agility and practical testing today as part of the hiring process. For the trauma scenario the patient had a flail chest and an open tib/fib fracture. Of the nine canidates that we had, only three of them even acknowledged the fact that the patient had a flail chest. Of those three only one used a bulky dressing against the flail segment. A second put the bulky dressing on the opposite side of the chest as the flail segment, and the third person said they could use a bulky dressing but that BTLS is teaching to no longer do that. (Could anyone out there verify if this is true?)

We were just surprised that the other six didn't even acknowledge the injury and were trying to figure out why that may be. Thanks for any input you guys may have!


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Old 04-19-2008, 06:39 PM   #2
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Originally Posted by Epi-do View Post
Just a quick question for everyone (I am also going to do my own research to see what I can find out on my own).

What is currently being taught to EMTs regarding the management of a flail chest?

I ask because we held a physical agility and practical testing today as part of the hiring process. For the trauma scenario the patient had a flail chest and an open tib/fib fracture. Of the nine canidates that we had, only three of them even acknowledged the fact that the patient had a flail chest. Of those three only one used a bulky dressing against the flail segment. A second put the bulky dressing on the opposite side of the chest as the flail segment, and the third person said they could use a bulky dressing but that BTLS is teaching to no longer do that. (Could anyone out there verify if this is true?)

We were just surprised that the other six didn't even acknowledge the injury and were trying to figure out why that may be. Thanks for any input you guys may have!

buly dressing on the side of the injury. Why anyone would put a bulky dressing on the reverse side? I have no idea. I am told this doesn't really work anyway.
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Old 04-19-2008, 07:19 PM   #3
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This is from PHTLS 6th Ed.

"Management of flail chest is directed toward pain relief, ventilatory support, and monitoring for deterioration. The respiratory rate may be the most important parameter to follow. Pulse oximetry, if available, is also useful to detect hypoxia. Oxygen should be administered and IV access obtained, except in cases of extremely short transport times. Support of ventilation with bag-valve-mask (BVM) assistance or endotracheal intubation and positive-pressure ventilation may be necessary (particularly with prolonged transport times). Efforts to stabilize the flail segment with sandbags or other means are contraindicated."

PHTLS, BTLS, ATLS; they're all sponsored by the American College of Surgeons.

The reason they don't want you to mechanically stabilize the flail segment is because of the pain. Two or more fractured ribs in two or more places creating a floating segment is going to hurt like hell. You're not likely to see it in the early phases due to spasms with the intercostal muscles causing a splint of the segment. You might be able to on palpation if they let you. Remember, it's going to hurt like hell.

If you see paradoxical movement, it's a late sign. By then, the pt will be hypoxic and so compromised, you'll need to bag them. THAT's the definitive treatment.
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Old 04-19-2008, 11:33 PM   #4
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Thanks alot Mike! I knew someone here would be able to help me out. I did also find a couple good articles that stated the same as the PHTLS book you quoted. I passed the information along to those involved in the hiring process (including our EMS chief, so hopefully there will be an upcoming training to update everyone to the latest information). In our scenario, there was crepitus and diminished breath sounds on the right. There was also supposed to be unequal rise and fall of the chest.

The reason for not mechanically stabilizing the chest makes total sense. All in all, it was a good scenario if for no other reason than it made me do some research and learn something new when the day was over.

Again, thanks for you help!
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Old 04-20-2008, 03:57 AM   #5
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Fascinating! Anyone have any other information? What about pain control prior to manual stabilization, ie: sandbag or bandaging? Isn't the point to reduce movement of the affected chestwall valid?

Any other BTLS/PHTLS revisions that have come about in the last 3 or so years?
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Old 04-20-2008, 07:02 AM   #6
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Flail Chest.

1. Have pt. take deep breath in, place bulky dressing in hole.
2. Have pt breathe out while you are holding bulky dressing, and at end of exhalation (sp?) tape in place.
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Old 04-20-2008, 07:54 AM   #7
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Flail Chest.

1. Have pt. take deep breath in, place bulky dressing in hole.
2. Have pt breathe out while you are holding bulky dressing, and at end of exhalation (sp?) tape in place.
Quote:
This is from PHTLS 6th Ed.

"Management of flail chest is directed toward pain relief, ventilatory support, and monitoring for deterioration. The respiratory rate may be the most important parameter to follow. Pulse oximetry, if available, is also useful to detect hypoxia. Oxygen should be administered and IV access obtained, except in cases of extremely short transport times. Support of ventilation with bag-valve-mask (BVM) assistance or endotracheal intubation and positive-pressure ventilation may be necessary (particularly with prolonged transport times). Efforts to stabilize the flail segment with sandbags or other means are contraindicated."
Efforts to stabilize the flail segment with sandbags or other means are contraindicated
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Old 04-20-2008, 08:07 AM   #8
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Flail Chest:

Give BVM to patient. Tell him that forcing air into his lungs will move his chest out together with the flail section minimizing pain. Sucking air in will cause the flail section to move opposite his ribs causing extreme pain.

They will gladly bag themselves.
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Old 04-20-2008, 10:59 AM   #9
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it does beg the question...

why, in the EMT curriculum, are we taught to stabilize with a bulky dressing, only to learn afterwards that this is contraindicated?

you can easily see the confusion...

most who have taken PHTLS will not stabilize, and most who have not taken PHTLS will stabilize...

must be an easier way!
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Old 04-20-2008, 11:08 AM   #10
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well has anyone seen the most recent "B" curriculum? Does anyone have a book from the past year or so laying around?
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