copyright © 2006 by mosby, inc. slide 1 part v chest and pleural trauma
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Copyright © 2006 by Mosby, Inc.Slide 1
Part VPart VChest and Pleural TraumaChest and Pleural Trauma
Copyright © 2006 by Mosby, Inc.Slide 2
Chapter 21Chapter 21Flail ChestFlail Chest
Figure 21-1. Flail chest. Double fractures of three or more adjacent ribs produce instability of the chest wall and paradoxical motion of the thorax. Inset,
Atelectasis, a common secondary anatomic alteration of the lungs.
Copyright © 2006 by Mosby, Inc.Slide 3
Anatomic Alterations of the LungsAnatomic Alterations of the Lungs
Double fracture of numerous adjacent ribsDouble fracture of numerous adjacent ribs
Rib instabilityRib instability
Lung restrictionLung restriction
AtelectasisAtelectasis
Lung collapseLung collapse
Lung contusionLung contusion
Secondary pneumoniaSecondary pneumonia
Copyright © 2006 by Mosby, Inc.Slide 4
EtiologyEtiology
Direct compression by a heavy objectDirect compression by a heavy object
Automobile accidentAutomobile accident
Industrial accidentIndustrial accident
Copyright © 2006 by Mosby, Inc.Slide 5
Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated
with FLAIL CHESTwith FLAIL CHEST
The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by AtelectasisAtelectasis (see Figure 9-7) and (see Figure 9-7) and Pneumonic ConsolidationPneumonic Consolidation (see Figure 9-8)— (see Figure 9-8)—the major anatomic alterations of the lungs the major anatomic alterations of the lungs associated with flail chest (see Figure 21-1).associated with flail chest (see Figure 21-1).
Copyright © 2006 by Mosby, Inc.Slide 6
Figure 9-7. Atelectasis clinical scenario.
Copyright © 2006 by Mosby, Inc.Slide 7
Figure 9-8. Alveolar consolidation clinical scenario.
Copyright © 2006 by Mosby, Inc.Slide 8
Clinical Data Obtained at theClinical Data Obtained at the Patient’s Bedside Patient’s Bedside
Vital signsVital signs
Increased respiratory rateIncreased respiratory rate Stimulation of peripheral chemoreceptors Stimulation of peripheral chemoreceptors
Other possible mechanismsOther possible mechanisms
• Decreased lung complianceDecreased lung compliance
• Activation of the deflation receptorsActivation of the deflation receptors
• Activation of the irritant receptorsActivation of the irritant receptors
• Stimulation of the J receptorsStimulation of the J receptors
• Pain/anxietyPain/anxiety
Increased heart rate, cardiac output, blood pressureIncreased heart rate, cardiac output, blood pressure
Copyright © 2006 by Mosby, Inc.Slide 9
Figure 21-2. Lateral flail chest with accompanying pendelluft.
Copyright © 2006 by Mosby, Inc.Slide 10
Figure 21-3. Venous admixture in flail chest.
Copyright © 2006 by Mosby, Inc.Slide 11
Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside
Paradoxic movement of the chest wallParadoxic movement of the chest wall
CyanosisCyanosis
Chest assessment findingsChest assessment findings Diminished breath soundsDiminished breath sounds
• On the affected as well as the unaffected sideOn the affected as well as the unaffected side
Copyright © 2006 by Mosby, Inc.Slide 12
Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special
ProceduresProcedures
Copyright © 2006 by Mosby, Inc.Slide 13
Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings
VT RV FRC TLC
N or
VC IC ERV RV/TLC%
N
VT RV FRC TLC
N or
VC IC ERV RV/TLC%
N
Copyright © 2006 by Mosby, Inc.Slide 14
Arterial Blood GasesArterial Blood Gases
Mild to Moderate Flail ChestMild to Moderate Flail Chest
Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia
pH PaCO2 HCO3- PaO2
(Slightly)
pH PaCO2 HCO3- PaO2
(Slightly)
Copyright © 2006 by Mosby, Inc.Slide 15
Time and Progression of Disease Time and Progression of Disease
100100
5050
3030
8080
00
PaCO2
1010
2020
4040
Alveolar HyperventilationAlveolar Hyperventilation
6060
7070
9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
PaO2
Disease OnsetDisease OnsetP
aO2
or
PaC
O2
PaO
2 o
r P
aCO
2
Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
Copyright © 2006 by Mosby, Inc.Slide 16
Arterial Blood GasesArterial Blood Gases
Severe Flail ChestSevere Flail Chest
Acute ventilatory failure with hypoxemiaAcute ventilatory failure with hypoxemia
pH PaCO2 HCO3- PaO2
(Slightly)
pH PaCO2 HCO3- PaO2
(Slightly)
Copyright © 2006 by Mosby, Inc.Slide 17
Time and Progression of DiseaseTime and Progression of Disease
100100
5050
3030
80
0
PaO2
1010
2020
4040
Alveolar HyperventilationAlveolar Hyperventilation
6060
7070
9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
PaCO 2
Acute Ventilatory Failure Acute Ventilatory FailureDisease OnsetDisease Onset
Point at which disease becomes severe and patient begins to become fatigued
Point at which disease becomes severe and patient begins to become fatigued
Pa0
2 o
r P
aC0 2
Pa0
2 o
r P
aC0 2
Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.
Copyright © 2006 by Mosby, Inc.Slide 18
Oxygenation IndicesOxygenation Indices
QS/QT DO2 VO2 C(a-v)O2
Normal (severe)
O2ER SvO2
QS/QT DO2 VO2 C(a-v)O2
Normal (severe)
O2ER SvO2
Copyright © 2006 by Mosby, Inc.Slide 19
Hemodynamic Indices Hemodynamic Indices (Severe Flail Chest)(Severe Flail Chest)
CVP CVP RAPRAP PAPA PCWPPCWP
COCO SVSV SVISVI CICI
RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR
Copyright © 2006 by Mosby, Inc.Slide 20
Radiologic FindingsRadiologic Findings
Chest radiographChest radiograph
Increased density Increased density
Rib fracturesRib fractures
Copyright © 2006 by Mosby, Inc.Slide 21
Figure 21-4. A, Chest X-ray film of a 20-year-old female with a severe right-sided flail chest. B, Close-up of the same X-ray film, demonstrating rib fractures
(arrows).
Copyright © 2006 by Mosby, Inc.Slide 22
General Management of General Management of Flail ChestFlail Chest
Mild casesMild cases
Medication for pain and routine bronchial Medication for pain and routine bronchial hygienehygiene
Severe casesSevere cases
Volume-controlled ventilation with PEEPVolume-controlled ventilation with PEEP 5 to 10 days usually adequate for sufficient bone 5 to 10 days usually adequate for sufficient bone
healinghealing
Copyright © 2006 by Mosby, Inc.Slide 23
General Management of General Management of Flail ChestFlail Chest
Respiratory care treatment protocolsRespiratory care treatment protocols
Oxygen therapy protocolOxygen therapy protocol
Hyperinflation therapy protocolHyperinflation therapy protocol
Mechanical ventilation protocolMechanical ventilation protocol
Copyright © 2006 by Mosby, Inc.Slide 24
Classroom DiscussionClassroom DiscussionCase Study: Flail ChestCase Study: Flail Chest
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