Pulmonary Contusion and Flail Chest, Management of

Published 2012

Level 1

There is no support for Level 1 recommendations regarding PC-FC.

Level 2

Trauma patients with PC-FC should not be excessively fluid restricted but rather should be resuscitated as necessary with isotonic crystalloid or colloid solution to maintain signs of adequate tissue perfusion. Once adequately resuscitated, unnecessary fluid administration should be meticulously avoided.

  1. A pulmonary artery catheter may be useful to avoid fluid overload during resuscitation.
  2. Obligatory mechanical ventilation in the absence of respiratory failure solely for the purpose of overcoming chest wall instability should be avoided.
  3. Patients with PC-FC requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure (PEEP)/continuous positive airway pressure (CPAP) should be included in the ventilatory regimen.
  4. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure and ensuing ventilatory support. Epidural catheter is the preferred mode of analgesia delivery in severe FC injury (see EAST PMG Analgesia in Blunt Thoracic Trauma).
  5. Steroids should not be used in the therapy of PC.

Level 3

  1. A trial of mask CPAP should be considered in alert, compliant patients with marginal respiratory status in combination with optimal regional anesthesia.
  2. There is insufficient evidence to prove the effectiveness of paravertebral analgesia in the trauma population. However, this modality may be equivalent to epidural analgesia and may be considered in certain situations when epidural is contraindicated.
  3. Independent lung ventilation may be considered in severe unilateral PC when shunt cannot be otherwise corrected owing to maldistribution of ventilation or when crossover bleeding is problematic.
  4. High-frequency oscillatory ventilation (HFOV) has not been shown to improve survival in blunt chest trauma patients with PC but has been shown to improve oxygenation in certain cases when other modalities have failed. HFOV should be considered for patients failing conventional ventilatory modes. The appropriate triggers for institution of HFOV have not been defined.
  5. Diuretics may be used in the setting of hydrostatic fluid overload as evidenced by elevated pulmonary capillary wedge pressures in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.
  6. Although improvement has not been definitively shown in any outcome parameter after surgical fixation of FC, this modality may be considered in cases of severe FC failing to wean from the ventilator or when thoracotomy is required for other reasons. The patient subgroup that would benefit from early “prophylactic” fracture fixation has not been identified.
  7. There is insufficient clinical evidence to recommend any type of proprietary implant for surgical fixation of rib fractures. However, in vitro studies indicate that rib plating or wrapping devices are likely superior to intramedullary wires and these should be used as the preferred fixation device.
  8. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.