Question

Thomas Good, a 56-year-old male arrives in the ED after being involved in a MVA. He was an unrestrained driver verses an 18-wheeler. There is extensive damage to the front of the car. The client needed to be extricated from the vehicle. He has massive bruising to the chest, head, and neck.

You are the ICU nurse: The report you receive from the ED nurse:

Sedated with versed 5 mg after receiving 20 mg Etomidate and 100 mg of succinylcholine for intubation. Prior to intubation the GCS was 7.

He will receive a Versed drip from the pharmacy, it will be tubed to the unit. Versed to run at 8 mg/hr. patient weight 180 lbs

8.0 endotracheal tube is in place 21 cm at the lip.

Vent settings are: Vent rate 12, TV (tidal volume) 500 ml, PEEP 5 ml, Fio2 21%

Chest tube to 20 cm of suction 200 ml of serious drainage, site dry and intact, Lungs sounds diminished, with wheezes upper airway, crepitus felt in upper left chest

Skin warm and dry

Several lacerations and bruising of the chest, neck, and head Febrile at 101, ST 110, RR 12, BP 100/64

Bowel sounds present all 4 quads, incontinent of urine and stool upon arrival to ED

You take over care: you begin your assessment; the vent alarms are going off. The respiratory therapist had to leave the room for a code. How do you care for the patient?

Is the client on the vent for ventilatory or oxygenation problem? What is the cause of the alarms?

What is the first action required? What is the next action required?

How will you position the client with a flail chest?

Answer 1

QUESTIONS:

• Is the client on the vent for ventilatory or oxygenation problem?
• What is the cause of the alarms?
• What is the first action required?
• What is the next action required?
• How will you position the client with a flail chest?

ANSWERS:

In this case, Thomas Good, a 56-year-old male is diagnosed with flail chest as result of MVA.

Flail chest

A flail chest describes when a segment of the rib cage breaks due to blunt thoracic trauma, high speed motor vehicle crash and becomes unattached from the chest wall. It can occur when 3 or more ribs are broken in at least two places, although not everyone with type of injury will develop a flail chest. However, if these injuries cause a segment of the chest to move independently, the generation of negative intrapleural pressure indicates a true paradoxical flail segment. This condition is of clinical significance in elderly patients or patients who have chronic lung disease, associated with morbidity and mortality.

Client is on ventilator for both ventilatory and oxygenation problems:

Ventilation: Exchange of air between the lungs and the air (ambient or delivered by a ventilator), in other words, it is the process of moving air in and out of the lungs. Its most important effect is the removal of carbon dioxide (CO2) from the body, not on increasing blood oxygen content. Ventilation is measured as minute ventilation in the clinical setting, and it is calculated as respiratory rate (RR) times tidal volume (Vt). In a mechanically ventilated patient, the CO2 content of the blood can be modified by changing the tidal volume or the respiratory rate.

Oxygenation: Interventions that provide greater oxygen supply to the lungs, thus the circulation.

For a person to draw a breath, the muscles around the rib cage and the diaphragm have to move to expand the chest cavity. This creates a vacuum that is filled as air enters the lungs. If this expansion is hindered, the ability to draw air into the lungs is diminished. A flail chest is a chest in which sections of broken ribs are isolated from, and interfering with, normal chest movements. That means the chest cannot expand properly and cannot properly draw air into the lungs. This leads to ventilatory problem. This may further leads to decreased oxygenation as a result of inadequate oxygen level in alveolar level for gas exchange (internal respiration).

The cause of alarm:

The cause of alarm can be due to changes in ventilator settings, possibly decrease in oxygen level (shows as decreased SPO2).

Actions required:

• Monitor ventilator settings immediately and find the changes in the ventilator parameters.
• Increasing the fraction of inspired oxygen (FiO 2%) or the positive end-expiratory pressure (PEEP) in case of decreased spo2.
• If patient condition is not stabilized change the mode of ventilator to higher grade according to hospital policy.
• Ventilator Management - supplemental oxygen therapy, continuous positive airway pressure or intubation if necessary

        -CPAP - for negative intrapleural pressure and paradoxical movement, increases TV

       -Open/closed suction if patient incubated.

Positioning patient with flail chest:

• Positioning in high sitting (Fowler’s position) and side lying
• This position promotes lung expansion.
• Fowler’s position is used for patients who have difficulty breathing because in this position, gravity pulls the diaphragm downward allowing greater chest and lung expansion.
• This position also promotes to relieve fluid and air through chest tube.

Conclusion:

Treatment of flail chest has changed over the years. When facing someone with flail chest, the goal of emergency room personnel is to stabilize the chest wall, followed by identification and treatment of all injuries in and around the chest. The significance of flail chest is it suggests the presence of underlying cuts and bruises on the lungs. After all, broken ribs have pointed, sharp or jagged edges. The injured ribs probably were knocked out of place and possibly against or into the lungs by the trauma. And proper breathing, of course, remains a critical consideration.