Rib plating and respiratory Mechanics · This leads to the clinical triad of flail chest descr對ibed by Williams et al that included Intrabronchial hemorrhage, ineffective cough,

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Case Presentation 48 M with PMHx of Bipolar disorder, previous suicide attempts,

polysubstance abuse, DM, and HLD presented to ED as Level 1 Trauma code as a pedestrian struck. Patient was seen jumping in front of a car, being flung to the ground and then being run over by a second car. He was GCS 13 on arrival

Vitals: 116/62, 99, 98.0, 16 Airway intact Breath sounds bilaterally Obvious L anterior chest wall deformity with flail chest and road rash Abdomen soft, non tender, non distended FAST positive for fluid in Morrison's pouch Pelvis stable


CXR


CT Chest


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CT Chest



Case presentation CT head: Negative

CT facial: R orbital fracture

CT C spine: Negative

CT Chest: Mild LUL and lingular contusions, Mild pleural

effusion and trace b/l pneumothoraxes <5%. Right 4,5,6,8,9,10 rib fractures non displaced, Left 2-6 fractures severely to moderately displaced; L 4th rib abuts the anterior wall of heart, severely displaced clavicular fracture.

CT A/P: Mild liver laceration with mild hematoma.


Hospital Course HD #1: Admitted to SICU for pain control and monitoring. Given the patient’s history with

substance abuse it was difficult to adequately control his pain and he desaturated to mid 80s and was intubated.

Noted to have progress drop in H/H from 13 -> 10 and hypotension but stable HR in the 60s and adequate UOP of 50cc/hr; hepatic angiogram performed by IR which was negative.

HD #2: Patient underwent Thoracotomy with stabilization of left ribs 2-5 via plating and left 6th rib stabilization via sternal wires; ligation of the internal mammary artery. Intraoperatively he was noted to have increasing airway pressures and was difficult to ventilate, a R sided chest tube was placed for presumed pneumothorax and his ventilatory issues resolved.


Hospital Course HD # 4: febrile to 102, pan cultured and started on empiric

antibiotics (Vanc/Aztreonam) Repeat CT chest performed to rule out PNA/empyema as

patient has worsening respiratory function and noted to have a large L sided pleural effusion that was not drained by the chest tube, a second chest tube was placed on the L side and evacuated 400cc of serosanguinous fluid.

HD # 6: BAL cultures positive for Klebsiella PNA, continued on antibiotics

HD #10: Chest tubes pulled

HD# 12: Patient self extubated

HD # 14: Patient transferred to inpatient psychiatry ward.


Questions???


Rib Fractures and the Flail Chest Flail chest is defined as 3 or more consecutive rib

fractures, that are fractured both anteriorly and posteriorly

First described in 1940s along with the rise of the automobile, as it increased in frequency and was termed “steering wheel injury”


Presenter

Presentation Notes

Multiple broken ribs that are broken in multiple places. This causes a section of the rib cage to be separate from the chest wall and causes a paradoxically movement with respiration. Steering wheel injury was the result of head on collisions that caused fractures of bilateral ribs along the sternum

Normal Respiration


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Presentation Notes

The muscles responsible for breathing are mainly the diaphragm and the intercoastals; at rest the atmospheric pressure within the lungs and outside the body are equal. When the muscles of respiration contract they cause a flattening of the diaphragm and lifting of the chest wall which increase lung volume and a decrease in pressure, this causes a negative pressure gradient that draws air into the lungs. For expiration it’s the opposite, diaphragm and intercoastals relax which decrease lung volume and increase pressure causing air to be pushed out.

Spirometry www.downstatesurgery.org

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Presentation Notes

FRC defined as the end of quiet expiration; it is where atmospheric and alveolar pressure are equal and there is no pressure gradient. Lungs stay “open” because there is a persistent negative pressure in the intrapleural space which is the equal forces of the chest wall which wants to stay expanded and the lung which want to collapse completely.



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Major patterns: Obstructive (decreased Fev1/fvc more than 75% predicted) Restrictive (decreased FVC and TLC) �Pseudorestriction (decreased FVC, but elevated TLC; this happens when there is so much obstruction that the lungs hyperinflated and crowd out the working lung and the portion left is restricted) Interstital lung issues (NL PFTs but Dlco is decreased) Neuromuscular issues (NL or decreased PFTs but DLCO is nl, this signals hypoventilation)

What happens in Flail Chest?


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Presentation Notes

The non fixed segment will be pulled inward during inspiration (generated by the negative pressure) which causes a local compression and atelectasis of that area altering normal alveolar recruitment, depending on the severity of the flail segment the mediastinum may be effected which can cause hemodynamic instability as well.

What happens in Flail Chest?


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Presentation Notes

The non fixed segment will be pulled inward during inspiration (generated by the negative pressure) which causes a local compression and atelectasis of that area altering normal alveolar recruitment, depending on the severity of the flail segment the mediastinum may be effected which can cause hemodynamic instability as well. Rib fractures are also noted to be quite painful, the pain with inspiration causes patients to alter their breathing and most splint, they decrease movement of the chest wall in order to reduce pain. This leads to the clinical triad of flail chest described by Williams et al that included Intrabronchial hemorrhage, ineffective cough, and anoxia.

“The disturbances of respiratory mechanics created by paradoxical respiration are easily controlled when there is no lesion of the lung. When the lung is injured the main problem is respiratory insufficiency created by temporary compromise of lung function” Garzon et al


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Presentation Notes

Rib fractures are also noted to be quite painful, the pain with inspiration causes patients to alter their breathing and most splint, they decrease movement of the chest wall in order to reduce pain. This leads to the clinical triad of flail chest described by Williams et al that included Intrabronchial hemorrhage, ineffective cough, and anoxia. These are the mechanics of flail chest, there is a secondary component of the lung parenchyma that is also injured underneath this flail segment that also contributes to respiratory compromise of flail chest.

Treatments Controversial; patient centered as three separate issues

are affected. Pain control/Analgesia is first line. If ineffective then more invasive measures used.

• Divided into two classes internal support and external support

• Internal support: Mechanical positive pressure ventilation

• External support: Non operative vs Operative


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Presentation Notes

Given the multifactorial nature of injury and respiratory compromise its not surprise that treatment options are vast. Three major systems affected 1) chest wall (mechanics) 2) Lung parenchyma (affects diffuse/function) 3) pain (hypoventilation) Internal support first described in 1950s by Carter et al, they gave pts trachs and placed them on intermittent positive pressure ventilation (trachs helped them control the secretions) Most of these studies average vent support for 10-14 days while lung recovers. “The disturbances of respiratory mechanics created by paradoxical respiration are easily controlled when there Is no lesion of the lung. When the lung is injured the main problem is respiratory insufficiency created by temporary compromise of lung function” Garzon, Seltzer and Karlson (actually written here at SUNY Downstate in 1968) Garzon et al discussed the changes to certain PFTs after crush injury; the compliance of lung is reduced by up to ¼ to ½ (means it’s stiffer and more pressure needed to change volume) Resistance was increased by 3x normal, increased minute ventilation all which lasted up to 10-12 days, diffusion capacity is decreased

When do we fix?? www.downstatesurgery.org

Benefits Granetzny et al “45 % of pts who underwent surgical fixation

required ventilator support for an average of 2 days, while those who underwent conservative therapy averaged 12 days”


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Presentation Notes

Granetzy paper: Surgery vs Strapping in a total of 40 pts. 20 each group Surgery group used K wires/stainless steel wires or both for stabilization and Strapping group used Elastoplast (for 7-10 days) taped around the fxs as a temporary cast (excluded anterior and superior fxs cuz you can’t tape first ribs) Surgery group had 85% of pts with a stable chest wall while only 50% of the Non op group achieved stability.

Marasco et al “Patients in the operative fixation group had significantly shorter ICU stays, with shorter ventilator requirements. No differences were noted in spirometry or quality of life at 3 or 6 months”

This study demonstrated a cost savings of $14,443 per patient who underwent rib stabilization.


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Presentation Notes

Enrolled only patients with flail chest requiring mechanical ventilation for >24 hrs; total of 46 pts Found that surgical pts required 285hrs on average in the ICU vs 359hrs in the non op group Vent support average of 3 hrs in the surgery group vs 50hrs in the non op group Used a questionnaire to measure quality of life, of note these patients generally suffered multiple injuries and it was noted that patients chronic complaints were global

Techniques www.downstatesurgery.org

Questions?

The sum of the four primary lung volumes (tidal volume, inspiratory reserve volume, expiratory reserve volume, and residual volume) equals

A: Functional residual capacity B: Vital Capacity C: Total Lung Capacity D: Maximum Ventilatory Volume


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Presentation Notes

C total lung capacity

Questions??

All the lung volumes can be measured by spirometry except

A: Tidal Volume B: Inspiratory Reserve Volume C: Expiratory Reserve Volume D: Residual Volume


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D: residual volume RV can be measured using Helium dilution test, Nitrogen washout, or body plethysmography

Questions??

Restrictive lung disease is best defined by which of the following parameters?

A: reduced diffusion capacity B: reduced FEV1 C: reduced FVC D: reduced TLC


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Presentation Notes

D

Questions??

The definition of obstruction of PFTs is best defined by

A: an FEV1/FVC that is less than 70 to 75% of predicted

B: an FVC that is less than 75% predicted C: a maximal midexpiratory flow that is less than

70 to 75% predicted D: total lung capacity that is less than 70 to 75% of

predicited


Presenter

Presentation Notes

A

References

Akash Bhatnagar, et al. Rib Fracture Fixation for Flail Chest: What is the Benefit?; American College of Surgeons: Aug 2012: Vol 215: No 2

Granetzny, et al. Surgical vs Conservative treatment of flail chest. Evaluation of the pulmonary status; Interactive Cardiovascular and Thoracic Surgery: 2005: Vol 5

Bemelman, et al. Historic overview of treatment techniques for rib fractures and flail chest; European Journal of Trauma and Emergency Surgery; 2010: Vol 36

Marasco, et al. Prospective Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail Chest; American College of Surgeons: 2013: Vol 216, No 5


Documents

Rib plating and respiratory Mechanics · This leads to the clinical triad of flail chest descr對ibed by Williams et al that included Intrabronchial hemorrhage, ineffective cough,