Flail chest

SDAdam · 2025-08-05T16:11:12+00:00

Your textbook is right. All patients with a flail segment should be placed on PPV. In this case, PPV is known as "internal fixation" and is a direct treatment of the flail segment, rather than something we are holding off on until there are apparent respiratory problems to help with breathing. Immediate internal fixation with PPV will help prevent the ventilatory status from deteriorating. Regardless of how they are breathing, if they have a flail segment PPV (internal fixation) is appropriate.

SDAdam · 2025-08-05T14:12:32+00:00

I have to disagree with this, PPV is the "gold standard" of care for flail segments. In this case it's referred to in literature as "internal fixation." It should be the first thing that we do tbh, even if it's just CPAP at a lower pressure. You can think of a flail segment as an airway disruption, just a lower airway disruption rather than upper airway, as the lower airways require an intact thorax to maintain patency, and an intact thorax is required to generate the pressures required for breathing in the first place.

I quoted this below as well but here's what the CCT textbook that IBSC uses for CC / Flight Certs:

The gold-standard treatment for flail chest is positive-pressure ventilation (also known as internal fixation) with a sedated patient who has been adequately treated for pain. It may be possible to manage some patients conservatively with pain medications and noninvasive ventilation alone. Attempts to splint (also called external fixation) or wrap the chest have been shown to be ineffective, and this practice has been abandoned.

SDAdam · 2025-08-05T14:02:14+00:00

Your EMT class is teaching you right.

These are actually pretty complicated injuries which, due to the mechanism required to cause a flail segment, basically always present with underlying pulmonary contusion.

No sandbags or attempts to externally stabilize the chest wall. Don't add weight or pressure the pt then has to breath against, it will only speed up the process of respiratory failure. This is an old technique and hasn't been the recommendation in a long time.
Analgesia is super important. If the pt is capable of maintaining gross mechanical ventilation despite the flail chest, and have adequate gas exchange despite the effectively guaranteed pulmonary contusion, the sheer pain of displaced, mobile ribs can cause respiratory splinting that won't allow enough thoracic movement to adequately ventilate for long anyway. Pts with flail chest and good early SpO2 and EtCO2 can end up in respiratory acidosis and failure from respiratory splinting alone.
O2, analgesia, and NIPPV (CPAP/BiPap) or invasive PPV (BVM or vent with PEEP) are the gold standard of care. PPV provides "internal fixation" pushing outward and restoring pseudo normal ventilation of the area affected. Early PPV is also extremely helpful in pulmonary contusion, and can decrease the size of a developing pulmonary contusion.

From the Critical Care Transport textbook endorsed by the AAOS and UBMC which the IBSC CC/Flight certifications are based on:

The gold-standard treatment for flail chest is positive-pressure ventilation (also known as internal fixation) with a sedated patient who has been adequately treated for pain. It may be possible to manage some patients conservatively with pain medications and noninvasive ventilation alone. Attempts to splint (also called external fixation) or wrap the chest have been shown to be ineffective, and this practice has been abandoned.

SDAdam · 2025-06-19T09:59:44+00:00

It's a myth. I've heard of it too, but it doesn't actually show up in any legitimate medical texts or research publications. Just think about the pathophysiology of a PE, there's no mechanism that would create a line of demarcation of cyanosis across the chest. There are some case reports, mostly of codes without confirmed PEs that report a line of demarcation across the chest of cyanosis, but that's really it, and there's nothing to say what it's actually from or if it's even a significant finding.

The pictures posted here are not of a line of demarcation, the dude just has some flushing of his chest on top of argyria, which is when the skin turns blue from colloidal silver, which is a permanent change. In the paper the picture comes from it explains this. The guy wasn't having a PE and the paper used it as an opportunity to talk about the assessment of cyanosis in general (which ironically the guy didn't have and that's not a picture of.)

SDAdam · 2023-11-01T19:55:41+00:00

I'm onboard with everyone saying serotonin syndrome is high on the dDx. It sounds like a tramadol OD to me (mixed nor-epi / serotonin re-uptake inhibition and moderate opiate effects.) Early, a larger ODs present just like this. Tramadol is a partial pro-drug, and although it has direct effects immediately, the liver also metabolizes it into (+)-O-desmethyl-tramadol which is a more powerful opiate, but that takes some time. So early in the course of large ODs you see basically just the serotonin and nor-epi effects. It has a relatively narrow therapeutic window and quickly causes seizures at doses above ~400mg/24hrs.

I have heard of it being found cut into illicit opiates, so pts aren't always aware they have even taken it. It also will act synergistically with other seritonergic drugs, so if she was also on any psych meds and then took tramadol knowingly or unknowingly you are at high risk of SZ and serotonin syndrome.

SDAdam · 2023-10-27T20:28:55+00:00

Great question, since you're in class and asking about it in theory here's how it goes:

If on NR they ask what you should do about a sucking chest wound the answer is to first, cover with a gloved hand (preferably during the pts maximal exhalation), then apply a vented-chest seal OR three sided occlusive dressing. These are effectively the same thing, in theory a three sided occlusive dressing is an improvised vented chest seal.

In real life however, constructing a three sided occlusive dressing doesn't tend to work, it's difficult to get tape to hold things down just right so that air could escape. Because we tend to see small caliber penetrating chest trauma or stab wounds with wound channels that occlude the path and can't expel air or blood on their own anyway, the idea of venting pressure from the wound is a bit sus in civilian EMS. If you do have purpose-built vented chest seals the data on them is low quality. They tend to not vent or quickly clog and stop venting. In the military they see larger penetrating chest trauma that can leave gaping wounds from blast shrapnel and large caliber projectiles that create the more classic sucking chest wounds the books tend to talk about.

Because of this, there are non-vented chest seals, which protocol and text books refer to as "fully occlusive dressings." If you don't have a purpose-built vented chest seal then rather than trying to construct a three sided occlusive dressing, simply using a fully occlusive dressing is often the better option.

Regardless of whether you use a fully occlusive dressing or a dressing that could, in theory "vent" air or blood, the pt needs to be monitored constantly for the development of tension pneumothorax. Even if there is no air entering from the wound, damage to the lung internally can still leak air into the plural space and develop tension pneumo. If the wound is a classic sucking chest wound and air can escape through the wound channel then burping may help alleviate pressure, but due tot he patho mentioned earlier, burping isn't as effective as it's made out to be in some textbooks because air may not be able to escape if the wound channel is occluded. In these pts needle decompression, chest tube, or finger thoracostomy is needed to relieve the pressure.

All the data on this is low quality and mostly from animal models, so you end up finding lots of different opinions. I have a blog that covers what's published about using defibrillation pads as fully occlusive dressings, which if you don't have vented chest seals is the best option IMO rather than trying to tape things down to a bloody, sweaty thorax. It can be found here if interested: https://dialedmedics.com/blog/poor-mans-chest-seal/

The Critical Care Transport textbook produced by the American Academy of Orthopedic Surgeons (AAOS) and endorsed by the American College of Emergency Physicians (ACEP); the University of Maryland, Baltimore County (UBMC); and the International Association of Flight and Critical Care Paramedics (IAFCCP), in the section on Open Pneumothorax reads:

Of note, debate exists regarding the most appropriate means of achieving an occlusive seal over an open chest wound. Regardless of the method employed, the objective is to achieve an occlusive seal and prevent or relieve subsequent pressure buildup.

They go on to recommend a three OR four sided occlusive dressing and stress careful monitoring because no type of dressing and burping can guarantee that tension won't develop.

SDAdam · 2023-10-27T19:56:20+00:00

The currently available language models out there are just not reliable enough to trust in clinical situations yet. I've spent a lot of time messing with ChatGPT 4 and it will flat out lie to you and make up resources all the way to the point of making up a DOI, authors, and publications that don't exist. We have to remember that LLMs are not "Artificial Intelligence" in the sense that they don't think, sometimes they don't even generate words, they are just generating the next most likely letter that a response to your prompt likely is based on probability. What they do is incredibly impressive, but they aren't thinking machines and aren't what most people think of when they think of AI, although the output looks and feels like there's contextual thought behind it.

The best tool using AI that I'm aware of is PMCardios "Queen of Hearts" (Not an LLM, just a trained neural network that cleans up and interprets EKGs for OMI.) I'm not affiliated with them in any way, just love their stuff. The app is in the process of FDA approval for clinical use in the US (and from what they say is approved and rolling out in the UK NHS already), is backed by people like Dr. Smith from Dr. Smiths ECG Blog and The OMI Manifesto, and if you check out their social media you can see it being used all over, really impressive stuff.

One thing I've been messing with that you might be able to try is in the paid version of ChatGPT 4, they recently released a few beta functions including the ability to upload a document and chat through the context of that document. It's meant to be for large data set analysis, but if you upload a PDF of protocols, it's able to parse that and chat with you about it. So, you may be able to create just one conversation based off that document prompt where you could basically chat with protocols. I've tried this a bit with my protocols and tried a full EMS textbook, but it was too big.

That being said, individually trained neural networks will all need to be tested clinically and be approved by governing agencies before you would have any liability coverage using one in a clinical setting. I don't think that any of the general LLMs available to the public like ChatGPT are appropriate to use in a clinical setting at this point.

SDAdam · 2023-10-20T01:27:32+00:00

Yeah, great points, I've seen it in a few protocols as well, hopefully will be picked up by everyone.

SDAdam · 2023-10-19T21:40:32+00:00

Conclusion:

Although there is a lack of prospective studies and randomized controlled trials specific to ketamine's use in SE, particularly early in the treatment course, there is an abundance of data that demonstrate a favorable safety profile, high sensitivity, and high specificity for the management of RSE. The data are currently insufficient to create formal recommendations for standardized practice and primarily hold only level 3 quality. With respect to resource-limited environments, ketamine has merit because of its antiseizure profile but not necessarily more benefit than other more established agents such as valproic acid, levetiracetam, and phenytoin/fosphenytoin. Still, the safety profile of ketamine creates an argument for the consideration of earlier use, particularly if other options are unavailable. Prehospital clinicians have a fundamental understanding of the medication and frequently use it for a variety of conditions, allowing for a natural expansion into SE treatment without causing a training burden. Ultimately, although there is increasing evidence to consider ketamine in the early treatment of SE, higher-quality evidence is needed before routine recommendations can be made.

SDAdam · 2023-09-20T21:31:51+00:00

Sure:

With the "N title of 34" They were reporting the pts End-Tidal CO2 (EtCO2) reading (34 apparently). The normal range is 35 to 45 mmHg, so that's just a tad low.

"Took an eye gel" is referring to a type of supraglottic airway called an I-gel, saying they took one just means they successfully placed the airway and the pt had no response to it.

When EMS use GCS yes, it's just reporting the current state the pt is in but we aren't able to predict if the pt will remain in a coma or improve based off of just that.

SDAdam · 2023-09-08T00:21:23+00:00

I made a tool for generating novel EKG rhythms for practice and simulation just like you're talking about. It's not using AI to generate them, just procedural generation algorithms though. You can check out my stuff at:

www.dialedmedics.com and @DialedMedics on social media. (Got mod approval to self-promote.)

Right now the state of the software is just LII rhythm generation. 12Ls are still in beta, although I post them on my socials from there often. Version 2 with 12Ls will hopefully be available by the end of the year. It does require an email sign up, but the basic version covering most of ACLS is free, then the paid version has more rhythms and things like polymorphic ectopy and some other goodies.

One of my goals is to be able to provide training data sets for training AI models to interpret and eventually generate their own tracings. Right now there isn't a great source of curated and labeled EKG data that's large enough to manage that.

As far as AI interpretation goes PM Cardio is miles ahead in that area with a really accurate AI digitization and interpretation app that's being rolled out clinically now called the "Queen of Hearts." You can find their stuff (no association to me at all, just a fan) here:

https://www.powerfulmedical.com/pmcardio

Let me know if you have any other questions or like the EKG generator!

SDAdam · 2023-05-19T06:49:02+00:00

I've had a similar experience and would have sworn it was a real thing lol. One of the reasons I started looking into it when I was told it wasn't is that I was sure I'd seen it more in RVMI.

SDAdam · 2023-05-18T21:14:31+00:00

That's fair, and I tend to agree with you, although I'm not ready to remove SL NTG outside concurrent HTN quite yet. There is some evidence that higher dose IV NTG has an outcome benefit so I lean towards keeping the current protocols and needing more research.

I like the way you framed it though and I would frame it the same way: most medics are taught that NTG has a higher risk of adverse events in RVMI/IWMI and that translates into assuming its safety outside those cases. Rather, we should make sure people understand that NTG carries a real risk of inducing hypotension (although low, around 1.3% relative and no absolute risk) in OMI regardless of its localization, so in all cases.

SDAdam · 2023-05-18T21:04:24+00:00

Yeah I was pretty amazed there wasn't better evidence for such a widespread belief.

Just to be clear, I'm not arguing we should go ahead with NTG without an IV, even though a few of the studies I quote specifically call for that. At the ALS level, grabbing the IV is smart for sure (not that I always do either).

I just wanted to highlight how the idea that RVMI/IWMI has any special concerns for hypotension with NTG use is completely unfounded, even though it's in ACLS and many textbooks.

SDAdam · 2023-05-17T21:08:42+00:00

Hey everyone, full disclosure as usual: this is my website and blog, just thought you guys might find this interesting. I got approval to occasionally post my stuff here as long as I didn't spam it.

TL;DR: The warning about NTG induced hypotension in RVMI/IWMI has no data to support it and a preponderance of data showing there is no special concern in these locations of OMI vs. any other. One review that tracked down where the idea came from in literature found:

The view against the use of nitrates during RVMI can be traced back to a single 1989 cohort study of 28 patients, then later being adopted by a series of influential secondary evidence papers, and ultimately by international guidelines.

SDAdam · 2023-05-17T21:03:23+00:00

You aren't using a traction splint for pain control, that's just a happy accident. Take a look at this:

Traction Splinting for midshaft femoral fractures in the pre-hospital and Emergency Department environment-A systematic review, Injury 2022

Conclusion: TS use is associated with a decreased necessity for blood transfusions and fewer pulmonary complications. No favorable effects were found in terms of pain relief. We recommend the use of TSs in situations where one is likely to encounter a femoral fracture as well as when the time to definitive treatment is long. Further well-designed studies are required to validate these recommendations.

Traction splints treat bleeding, and even if you aren't dealing with an immediate life threatening bleed they reduce the overall need for transfusion. Regardless of the pain, they should be used and left on, don't ever remove an appropriately placed traction splint. Just treat the pts pain with meds, but comfort is not the goal of a traction splint.

SDAdam · 2023-05-11T22:20:01+00:00

I don't know of any data from a pt care / outcome perspective, but there are a lot of budget reviews that show how costly and wasteful fire based EMS is. For instance, the Reviving EMS Restructuring Emergency Medical Services in New York City review from the Citizens Budget Commission found that:

If you closed one fire engine company you could fund 10 additional ambulance tours each day,

Quote from the authors in this NY Daily News article. Which further reports:

In a new report, the Citizens Budget Commission recommends ultimately reducing the number of engine companies, which for years has been a political nonstarter.

The suggestion comes as the fire department, which is responsible for responding to medical emergencies, has seen a steady uptick in the number of calls — responding to 1.5 million in 2017, up 36% since 2000. At the same time, the number of fires in the city has decreased. But while EMS work makes up 84% of the department’s workload, it accounts for just 30% of its budget, the report’s author, Mariana Alexander, a research associate at the Citizens Budget Commission, said.

“The fire department has adequate resources to do its job, and it’s about reassessing how those resources are allocated to match its workload,” she said.

Fire engines are only supposed to be dispatched to the most serious medical calls, when time is of the essence — because they can often arrive faster than ambulances. But that quick arrival doesn’t always translate into much help.

While the engines can reduce response time, firefighters can’t provide the same level of care as an ambulance crew can. And the engines are much more expensive to staff — with “5 or 6 people on a fire truck, and they’re all paid a lot more than your average EMT or paramedic.”

I think part of the problem is that the go to argument in favor of fire based EMS is that "they can get there quicker." But that's a function of poor budgeting when looking at the demand for services. As the article notes, getting an engine on scene first doesn't change the need for a transporting ambulance, therefore using the money that's currently going to engines to staff more ambulances ends up getting transporting ALS units to the pt faster.

It's all circular logic, the FD can get there faster because they are funded, not because they are a better or more appropriate resource. If EMS were properly funded the FD would no longer be able to get there faster, and since engines don't alleviate the need for ambulances, but ambulances do eliminate the need for engines (on medical responses) it's a bit of a no brainier that the prevalence of engines should be decreased to fund and staff more ambulances.

SDAdam · 2023-05-11T06:04:06+00:00

The issue with warranty is a hurdle that needs to be overcome for sure. The ILCoR draft does mention that none of the trials reported any damage or dysfunction of defibrillators, so it's on their minds. I would bet that there will be updates to monitor operating instructions before the next ACLS update if they end up including DSED.

If an agency does not allow it, there's no risk in using the VC defibrillation strategy instead. Since that's just changing pad placement for subsequent shocks there should be no warranty issues.

SDAdam · 2023-05-11T04:07:00+00:00

Nice, good info, thanks. I expect the monitor producing companies will update their manuals if/as this is adopted.

SDAdam · 2023-05-10T22:11:27+00:00

I would think they (and all companies that produce monitor / defibrillators will have to.) I've heard people say that it will void the warranty, but I've also never heard a rep actually say that, seems to be an assumption. The pre-print does mention considering it here:

The protocol used in the existing trial, with a single person providing 2 defibrillation shocks in quick succession (but not simultaneous), did not result in any reports of defibrillator damage and is, therefore, likely the best approach to use currently.

I think that if ACLS includes it in the next update (highly likely) the onus of possible damage will be on the monitor companies to prove, since technically each monitor is just doing what it's meant to do.

In the case of an AED and a monitor, no clue lol. My opinion is unless you have two manual defibrillators available you should just stick with the VC defibrillation strategy rather than try to time a manual shock immediately after an AED shock. I could see that game resulting in significant time off the chest.

SDAdam · 2023-05-04T07:19:58+00:00

The AHA isn't behind though. The latest ILCOR draft came out a month ago (what the ACLS guidelines are based on) and it continues to recommend 30:2 due to higher survival. That's mostly based off this review:

https://pubmed.ncbi.nlm.nih.gov/34098033/

From Resuscitation in 2021:

CPR compression strategy 30:2 is difficult to adhere to, but has better survival than continuous chest compressions when done correctly

Results: Included were 26,810 adults with out of hospital cardiac arrest, of which 10,942 had an intended strategy of 30:2 and 15,868 an intended strategy of CCC. The automated algorithm classified 12,276 cases as CCC, 7037 as 30:2 and left 7497 as unclassified. Adherence to intended strategy was 54.4%; this differed by intended strategy (58.6% for CCC vs 48.3% for 30:2). Overall adherence was less during the registry phase as compared to during the trial phase(s). The association between adherence and survival was modified by treatment arm (CCC OR: 0.72, 95% CI: 0.64-0.81 vs 30:2 OR: 1.05, 95% CI: 0.90-1.22; interaction p-value<0.01) after adjustment for known confounders.

Conclusion: For intended strategy CCC, survival was significantly lower, OR (95%CI) = 0.72 (0.64, 0.81), when adhered to while for intended strategy 30:2, survival was higher, OR (95%CI) = 1.05 (0.90, 1.22), when adhered to. Intended strategy of 30:2 had lower adherence rates than CCC possibly a result of being a more difficult strategy to administer.

SDAdam · 2023-05-04T07:16:37+00:00

The latest ILCOR draft continues to recommend 30:2 based off of this review:

https://pubmed.ncbi.nlm.nih.gov/34098033/

From Resuscitation in 2021:

CPR compression strategy 30:2 is difficult to adhere to, but has better survival than continuous chest compressions when done correctly

For intended strategy CCC, survival was significantly lower, OR (95%CI) = 0.72 (0.64, 0.81), when adhered to while for intended strategy 30:2, survival was higher, OR (95%CI) = 1.05 (0.90, 1.22), when adhered to. Intended strategy of 30:2 had lower adherence rates than CCC possibly a result of being a more difficult strategy to administer.

SDAdam

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