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Lesson

Flail Chest & Pulmonary Contusion

10 min Trauma Skip to quiz

Objective: Recognize flail chest. Give oxygen. Treat pain so the patient can breathe. Expect the lung bruise under the flail to get worse during transport.

Why this matters

A piece of chest wall moves the wrong way. Some crews want to tape a bag of fluid to it. The injury that impairs gas exchange is usually the bruised lung under the flail, called a pulmonary contusion. Give oxygen. Support ventilation if the patient is tiring. Treat pain so they can breathe and cough. Do not weigh the segment down.

Key points
  • Give high-flow oxygen. Use continuous positive airway pressure (CPAP), or another form of positive-pressure ventilation, if the patient is tiring and your protocol allows it. Watch for pneumothorax, which is air in the pleural space.
  • Treat pain per protocol. A pillow the patient holds is comfort. It is not a weight taped to the chest. This site does not list a milligram dose.
  • This is a trauma-center chest injury. Chest-wall instability is a highest-level triage finding.
Verbalize
  • High-flow oxygen. If we ventilate, watch for tension pneumothorax.
  • Pain control so they can breathe.
  • Do not weigh the flail segment down.
  • This patient needs a trauma center.

Clinical sequence

  1. Give high-flow oxygen. Use CPAP or positive-pressure ventilation if the patient is tiring and protocol allows it. Watch for pneumothorax and for tension pneumothorax, which is air under pressure that is impairing circulation.
  2. Treat pain per protocol so the patient can take a breath. A pillow they hold is comfort. Do not tape an IV bag or a sandbag to the segment.
  3. Go to a trauma center. Do not send this patient to a clinic because it "is only ribs."

Teaching points

  • Flail chest means two or more ribs broken in two or more places. The loose segment moves in when the patient breathes in, and out when the patient breathes out.
  • The contusion worsens over hours. A saturation that looks acceptable on scene can fall during transport. Reassess.
  • Do not strap weights or a full IV bag onto the segment. That worsens collapsed air sacs and makes ventilation worse.
  • Needle only for tension physiology. Flail chest and tension can exist together. Do not needle a simple pneumothorax.

Common errors

  • Sandbagging the segment or taping a full IV bag onto it.
  • Withholding pain medicine so the patient will not take a breath.
  • Sending the patient to a clinic because it looks like "only ribs."

Practice

One-minute check

After a side-impact crash you see a chest segment that moves in when the patient breathes in. Oxygen saturation is 91% and the patient is screaming. Say the oxygen plan, the pain plan, the destination, and what you will not tape to the chest.

Related: Tension, Chest seals.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. You see a paradoxical chest-wall segment (flail). Best field plan is:
2. The injury that actually wrecks gas exchange under a flail is often:
3. Sat 94% on scene with a flail chest. What should you expect?
4. Taping a full IV bag onto the flail segment is:
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