Closed Chest Injury - Flail Chest

14th March 2024


Closed chest injuries are much more common than open chest injuries but may still require urgent evacuation, robust treatment and regular observation.

The basic management of a singular - or even multiple - broken ribs is largely pain relief and comfortable positioning. A more sinister injury is flail chest - where more than one rib is broken in more than one place allowing for movement of the damaged section, often described as paradoxical breathing as the flail segment will move in the opposite direction to the rest of the chest during the breathing cycle.

Positioning

For a long time, it has been taught to position the casualty INJURED SIDE DOWN to stabilise the injury.

The 2013 RCS FPHC Consensus Statement on The pre-hospital management of life-threatening chest injuries (1) recommends the optimal position for gas exchange is sitting up, or lying with the INJURED SIDE UP (2-6) (although this is often neither practical nor possible).

This has changed since the 2007 Consensus Statement. Also, the recommendation to "splint" the damaged section has been removed, given the lack of supporting evidence and that it may actually impair ventilation (7).


Treatment

  • If conscious, sit the patient up to aid respiratory function if tolerated, if not, position the injured side UP if possible.

  • The casualty may self-splint with their hand for comfort but do not actively splint which may impair respiration. If the casualty is conscious, consider pillows for comfort, depending on positioning.

  • Consider Pain relief. Paracetamol cannot be underestimated as well as combination therapies. Methoxyfluorane (Penthrox® ) if available. Chest injury is a contraindication for nitrous oxide (Entonox® ) and opiates.

  • Ventilation is not required unless there is respiratory failure.


Further Reading - Open Chest Injury


References:

  1. https://fphc.rcsed.ac.uk/media/1788/management-of-chest-injuries.pdf

  2. Lee C, Revell M, PorterK, et al.  (2007)  “The prehospital management of chest injuries: a, consensus statement”.  Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh. Emergency Medical Journal.  24:220–4.

  3. Dean E. (1985) “Effect of body position on pulmonary function”. Physical Therapy. 65(5):613-618.

  4. Clauss RH, Scalabrini BY, Ray JF, et al. (1968). “Effects of changing body position upon improved ventilation- perfusion relationships”. Circulation. 37(Suppl2):214-217.

  5. Remolina C, Khan AV, Santiago TV, et al. (1981). “Positional hypoxemia in unilateral lung disease”. New England Journal of Medicine. 304:523-525.

  6. Sonnenblick M, Melzer E, Rosin AJ. (1983) “Body positional effect on gas exchange in unilateral pleural effusion”. Chest. 83:784-786.

  7. Association of Ambulance Chief Executives. UK Ambulance Services Clinical Practice Guidelines 2013, Bridgwater 2013.