Abstract Flail chest is a severe consequence of blunt thoracic trauma, resulting in paradoxical chest wall motion that compromises ventilation efficiency, impairs gas exchange, and leads to significant respiratory complications. We present an uncommon case of bilateral flail chest after mechanical cardiopulmonary resuscitation with complete recovery. Case A 76-year-old male with hypertension, type 2 diabetes mellitus, tobacco use disorder, and smoldering myeloma was admitted to the intensive care unit (ICU) after out of hospital cardiac arrest (OHCA) while undergoing outpatient magnetic resonance imaging. He underwent cardiopulmonary resuscitation with return of spontaneous circulation and was intubated in the field. After admission to the ICU, workup was negative for cardiac, metabolic or obstructive cause of his presentation. The OHCA was theorized to be secondary to an anaphylactic reaction to gadolinium contrast. The patient was successfully extubated to BiPAP, transitioned to high flow nasal cannula (HFNC), and transferred to the step-down care unit with intact neurologic function. The patient was also diagnosed with COVID-19 infection with superimposed bacterial pneumonia, and initiated on broad spectrum antibiotics and steroids. The pulmonary team was consulted for persistent respiratory failure. On evaluation, the patient was noted to have a paradoxical breathing pattern, with outward motion of the bilateral sternum on exhalation, and inward motion on inhalation. The flail chest mechanism was likely contributing to his delayed recovery. Repeat chest CT showed bilateral displaced fractures of ribs 2 through 6 anteriorly, a large left pleural effusion, and left lower lobe atelectasis. Cardiothoracic surgery recommended staged video-assisted thoracic surgery (VATS) with decortication, followed by rib fixation. Pleural cultures grew vancomycin-resistant Enterococcus, and antibiotics were adjusted per infectious disease recommendations. The patient subsequently underwent bilateral rib plating with complete resolution of paradoxical breathing. He recovered well, was discharged to a skilled nursing facility on room air, and later returned to his home without respiratory complications. Discussion Flail chest is a serious thoracic injury causing paradoxical chest motion, impaired ventilation, and respiratory complications. Early recognition is essential to prevent associated morbidity. Mild cases may be managed conservatively with analgesia and pulmonary support. Literature suggests that early surgical stabilization is associated with improved pulmonary function, reduced ICU length of stay, and decreased mortality, and should be considered in patients with respiratory compromise. This abstract is funded by: None
Baidwan et al. (Fri,) studied this question.