Introduction
A 63-year-old male was brought to the emergency department following a high-impact road traffic accident in which his car was struck by a lorry. On arrival, he was in severe respiratory distress with hypoxia and hemodynamic instability. Clinical evaluation revealed multiple rib fractures with bilateral flail chest, bilateral hemopneumothorax, extensive subcutaneous emphysema, and pneumomediastinum. He was promptly intubated and initiated on mechanical ventilation, and bilateral intercostal drainage tubes were inserted. Despite these measures, he had persistent hypoxemia and shock requiring aggressive management.
Respiratory Challenges and Interventions
Ventilatory management was particularly challenging due to bilateral flail chest, limiting prone positioning. The patient was managed in the supine position with optimized ventilator strategies. During the ICU stay, he developed worsening oxygenation, and imaging suggested lung collapse. Emergency bedside bronchoscopy revealed airway obstruction with secretions, which were cleared, resulting in improvement. Due to anticipated prolonged ventilation and significant laryngeal edema, a bronchoscopy-guided percutaneous tracheostomy was performed.
Multisystem Involvement
The patient developed acute kidney injury (AKI), managed conservatively with careful fluid and renal monitoring. He also developed acute abdominal distension, which compromised respiratory mechanics. Prompt evaluation and management improved ventilatory status.
Supportive Care
Management included adequate analgesia for rib fractures, targeted antimicrobial therapy for infections, early physiotherapy, pulmonary rehabilitation, and optimized nutritional support to facilitate recovery.
Outcome
There was gradual improvement in respiratory function, allowing successful weaning from mechanical ventilation. The patient was subsequently decannulated and shifted to the ward in stable condition.
Conclusion
This case highlights the complexity of managing severe thoracic trauma with flail chest and multisystem involvement. A multidisciplinary critical care approach, timely interventions, and meticulous supportive care were key to achieving a favorable outcome.
