Flail chest with coagulopathy causes high mortality aggravated by acidosis and hypothermia

Dedy Chandra Hariyono; Darmawan Ismail; Azzahra Fadhlila Aulia Nisa

doi:10.18203/2349-2902.isj20233359

Authors

Dedy Chandra Hariyono Surgery Resident of Sebelas Maret University, Surakarta, Indonesia
Darmawan Ismail Department of Thoracic and Cardiovascular Surgery Dr. Moewardi Regional General Hospital, Surakarta, Central Java, Indonesia
Azzahra Fadhlila Aulia Nisa Department of Clinical Medical Student, Dr. Moewardi Regional General Hospital, Surakarta, Central Java, Indonesia

DOI:

https://doi.org/10.18203/2349-2902.isj20233359

Keywords:

Flail chest, Hypothermia, Coagulopathy, Acidosis, Trauma, Mortality

Abstract

Flail chest is a condition where the ribs are broken in 2 or more places in successive ribs. The most common cause is blunt force trauma due to motorcycle accidents, falls or other conditions of bone abnormalities (congenital abnormalities, bone fragility) in young children or the elderly. This flail chest condition causes paradoxical movement of the chest when breathing. In line with the different breathing movements (moving inwards on inspiration and moving outward on expiration) this fracture compartment of the bone can injure the surrounding tissues which can cause complications such as pulmonary contusion with coagulopathy, inadequate ventilation which causes hypoxemia, and hypoventilation which causes acidosis due to reduced oxygenation of the tissues. Flail chest can also cause bleeding which ends in hypoperfusion causing hypothermia which will exacerbate coagulopathy. Flail chest is an important thing that needs to be assessed early after trauma so that no bad complications occur that lead to the triad of death (coagulopathy, acidosis, and hypothermia). Flail chest is an emergency condition frequently caused by blunt thoracic trauma. If it develops to pulmonary contusion it will lead to fatal condition implicates triad of death especially coagulopathy impaired by acidosis and hypothermia.

Metrics

Metrics Loading ...

References

Perera TB, King KC. Flail Chest. Treasure Isl StatPearls Publication. 2023;6-11.

Athanassiadi K, Theakos N, Kalantzi N, Gerazounis M. Prognostic factors in flail-chest patients. Eur J Cardio-thoracic Surg. 2010;38:466-71.

Simon B, Ebert J, Bokhari F, Capella J, Emhoff T, Hayward T et al. Management of pulmonary contusion and flail chest : An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5):S351-61.

Koesbijanto H. Flail Chest Management in ARDS. Folia Medica Indones. 2011;47(3):191-7.

Alanwer KM, Refat AM, Negm EM. Impact of flail chest injury on morbidity and outcome : ten years ’ experience at a tertiary care hospital in a developing country. BMC Anesthesiol. 2023;229:1-11.

Dogrul BN, Kiliccalan I, Asci ES, Peker SC. Blunt trauma related chest wall and pulmonary injuries: An overview. Chinese J Traumatol. 2020;23(3):125-38.

Yeh DD, Lee J. Trauma and Blast Injuries. In: Murray and Nadel’s Textbook of Respiratory Medicine. Sixth Edit. Elsevier Inc.; 2016;1354-66.

Athanassiadi K, Gerazounis M, Theakos N. Management of 150 flail chest injuries : analysis of risk factors affecting outcome. Eur J Cardio-thoracic Surg. 2004;26:373-6.

Tzeng W, Tseng H, Hou T, Chou S, Su W, Hsu S et al. From Death Triad to Death Tetrad-The Addition of a Hypotension Component to the Death Triad Improves Mortality Risk Stratification in Trauma Patients : A Retrospective Cohort Study. Diagnostics. 2022;12(11):2885.

Article R. Lung Contusion: A Clinico-Pathological Entity with Unpredictable Clinical Course. Bull Emerg Trauma. 2013;1(1):7-16.

Savioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. Medicines. 2021;8(4):1-22.

Hayakawa M. Pathophysiology of trauma-induced coagulopathy : disseminated intravascular coagulation with the fibrinolytic phenotype. J Intensive Care. 2017;5(14):1-7.

Moore EE, Moore HB, Kornblith LZ, Neal MD, Mutch NJ, Schöchl H et al. Trauma-induced coagulopathy. Nat Rev Dis Prim. 2022;7(30):1-54.

Nieuwenhuizen L, Groot PG De, Grutters JC, Biesma DH. A review of pulmonary coagulopathy in acute lung injury, acute respiratory distress syndrome and pneumonia. Eur J Haematol. 2009;82(6):413-25.

Brohi K, Cohen MJ, Ganter MT, Schultz MJ, Levi M, Robert C. Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis. J Trauma. 2008;64(5):1211-7.

Gando S, Sawamura A, Hayakawa M. Trauma, Shock, and Disseminated Intravascular Coagulation. Ann Surg. 2011;254(1):10-9.

Wright AP, Wade CE, Camp EA, Caga-anan Z, Zayde A, Minei KM et al. Pulmonary Contusion on Admission Chest X-ray is Associated with Coagulopathy and Mortality in Trauma Patients. J Emerg Med Trauma Surg Care. 2015;1-14.

Weuster M, Mommsen P, Pfeifer R, Mohr J, Ruchholtz S, Flohé S et al. Induced Hypothermia Does Not Harm Hemodynamics after Polytrauma: A Porcine Model. Mediators Inflamm. 2015;2015.

Veelen MJ Van, Maeder MB. Hypothermia in Trauma. Int J Environ Res Public Heal. 2021;18:8719.

Mitra B, Tullio F, Cameron PA, Fitzgerald M. Trauma patients with the ‘triad of death.’ Emerg Med J. 2012;29(8):622-6.

Martini WZ. Coagulopathy by Hypothermia and Acidosis: Mechanisms of Thrombin Generation and Fibrinogen Availability. J Trauma Inj Infect Crit Care. 2009;67(1):202-9.

Midwinter MJ, Woolley T. Resuscitation and coagulation in the severely injured trauma patient. R Soc. 2011;366:192-203.

Lier H, Krep H, Schroeder S, Stuber F. Preconditions of Hemostasis in Trauma: A Review. The Influence of Acidosis, Hypocalcemia, Anemia and Hypothermia on Functional Hemostasis in Trauma. J Trauma. 2008;65(4):951-60.

Staikou, Chryssoula Paraskeva A, Drakos E, Anastassopoulou I, Papaioannou E, Donta I et al. Impact of Graded Hypothermia on Coagulation and Fibrinolysis. J Surg Res. 2011;167(1):125-30.

Thorsen K, Ringdal KG, Strand K, Søreide E, Hagemo J, Søreide K. Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury. He Br J Surg. 2011;98(7):894-907.

Qadan M, Gardner SA, Vitale DS, Lominadze D, Joshua IG, Jr HCP. Hypothermia and Surgery: Immunologic Mechanisms for Current Practice. Ann Surg. 2010;250(1):134-40.