Flail Chest & Pulmonary Contusion
Objective: Recognize flail chest, oxygenate, treat pain so they can breathe, and expect the contusion to get worse in the truck.
Why This Is Hard
A segment floats the wrong way and someone wants to tape a IV bag to it. ATLS: the pulmonary contusion under the flail is what kills. Oxygen, ventilation support, pain control so they can cough and breathe.
- High-flow oxygen. CPAP/PPV if they tiring and protocol allows — watch for pneumothorax.
- Pain control per protocol. Splinting with a pillow they hold is comfort, not a sandbag.
- This is a trauma-center chest.
Field Rules (Education)
- Flail: two or more ribs broken in two or more places, segment moves paradoxically.
- Contusion worsens over hours. Sat that looks okay on scene can fall en route.
- Do not immobilize the segment with weights. That worsens atelectasis.
- Needle decompression if they declare tension — flail and tension can coexist.
Field Pitfalls
- Sandbagging the segment.
- No analgesia so they will not take a breath.
- Clinic destination.
Practice
60-second drill
Partner: lateral MVC, paradoxical segment, sat 91%, screaming. Oxygen, pain, what you will not tape on 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.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- ATLS education — flail chest: the contusion is the problem; do not restrict the segment
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.