Chest wall stabilization in a patient with severe TBI: A case report

Flail chest is a serious complication that may arise secondary to thoracic trauma and is associated with increased morbidity and mortality. In a flail chest, paradoxical chest movement decreases the functional residual capacity, leading to hypoxia, hypercapnia, and atelectasis. Adequate ventilation, fluid and pain management have classically been the cornerstones to flail chest treatment, with operative fixation being utilized in specific cases. Traumatic brain injury (TBI) has historically been believed to be an absolute contraindication for surgical fixation of rib fractures (SSRF); however, emerging studies have shown a favorable prognosis in select patients who underwent SSRF with severe TBI (Glasgow Coma Scale ≤8).

A 66-year-old male was brought into the Emergency Department by EMS following a traumatic injury that resulted in multiple rib fractures, spinal fractures, and traumatic brain injury. On hospital day 3, the patient underwent SSRF to repair bilateral flail chest. SSRF stabilized cardiopulmonary physiology, improving this patient's hospital course and avoiding the need for a tracheostomy. Herein, we report the successful use of SSRF in a flail chest patient with severe TBI that improved outcomes without evidence of secondary brain injury.

TBI is a severe condition that often presents with other injuries. Chest wall injuries (CWI) with concurrent TBI remain a significant challenge for clinicians as one set of injuries may exacerbate the other [10]. Through respiratory physiology and predisposition to pneumonia, CWI may lead to prolonged cerebral hypoxia resulting in secondary brain injury-worsening severe TBI. SSRF improves outcomes in polytrauma patients exhibiting CWI with TBI.

Surgical management of rib fractures has an essential role in select patients with severe TBI. Further research is warranted to improve our understanding of the complex interplay between the physiology of respiratory mechanics and the neurologic system in the trauma population suffering from TBI.