MEDICAL MANAGEMENT OF BILATERAL FLAIL CHEST CAUSED BY PROLONGED CPR

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Flail chest is a life-threatening condition caused by blunt trauma to the chest resulting in fractures of three or more consecutive ribs in two or more places with paradoxical motion. We present a rare case of bilateral flail chest secondary to trauma from manual CPR that recovered without surgical intervention. CASE PRESENTATION: A 65-year-old man presented to our hospital with MI, complicated by VF and cardiac arrest. He was emergently intubated and after 42 minutes of manual CPR he had ROSC. Several attempts at weaning the AC/PC were unsuccessful due to agitation, desaturation, tachypnea. CT chest showed acute fractures of lateral right fourth, anterior right fifth, anterior right sixth, lateral left fourth, anterior left fifth, and anterior left sixth ribs in addition to inward movement of the chest. There was a conservative strategy due to the high risk of bleeding on Ticagrelor and persistent fever (pan-sensitive MSSA on respiratory culture). Pain was managed with Precedex, Hydromorphone, and Midazolam drips then transitioned to Propofol and Gabapentin. He was then started on Oxycodone and Seroquel. On hospital day 25 the patient was weaned off Propofol, was A&O, and transitioned to tracheostomy collar/Fentanyl Patch. DISCUSSION: It is believed that the mortality from flail chest is secondary to complications rather than the flail chest itself, although visceral chest wall injuries such as pulmonary contusions and hemothorax are common. Nevertheless, without proper sedation/pain management (successive use of analgesics/sedatives with different pharmacological properties), and cautious attention to possible complications (VAP, mucous plugging, pulmonary contusions), this patient may have suffered from increased M&M.Pain control was difficult in an awake state; hence he was placed on Propofol for almost the entirety of his stay. At one point he was receiving high dose Hydromorphone, Oxycodone, Precedex, and Propofol. While there may be significant morbidity and additive effect of multiple opioids/sedatives, it was only with meticulous and slow discontinuation of these sedatives that the patient was able to successfully wake up with good pain control and relatively minimal delirium. While epidural/paravertebral blocks were considered, the patient’s DAPT precluded the their use. Secondly, because of the patient’s unusual distribution of fracture, regional anesthesia, would have also been difficult and short-lived. Early tracheostomy was warranted in this situation for comfort, pulmonary toilet, reduction of dead space, and sedative needs. CONCLUSIONS: Rib fractures and flail chest can produce significant morbidity for the elderly. Pain control, pulmonary toilet, and volume expansion measures are critical to reducing complications and further M&M. While surgical fixation continues to be controversial, medical management of even the most severe cases of flail chest can be successful. Reference #1: Phillips B, Murray E, Holzmer S . Bilateral Flail Chest: A review. Journal of Trauma and Orthopaedic Surgery.April - June 2017;12(2):2-7. Reference #2: Dehghan N, de Mestral C, McKee MD, et al. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg 2014; 76:462. Reference #3: R.S. Hoke, D. Chamberlain. Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation, 63 (2004), pp. 327-338. DISCLOSURES: No relevant relationships by Hany Abdallah, source=Web Response no disclosure on file for Leila Hosseinian