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\begin{document}

\title{Use of a pectus bar for surgical stabilization of cardiopulmonary
resuscitation induced flail chest}



\author[1]{SungKwang Lee}%
\author[1]{dohyung kim}%
\author[1]{Chee Hoon Lee}%
\affil[1]{Pusan National University Yangsan Hospital}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
A flail chest can occur when cardiopulmonary resuscitation causes
extensive rib fractures. Despite successful cardiopulmonary
resuscitation, if the flail chest is not treated, the patient may not
survive regardless of the correction of the primary condition that
caused the cardiac arrest. Therefore, if flail chest persists despite
proper conservative management to correct the flail chest, active
surgical management is essential. We present a successful surgical
treatment with pectus bar for a patient with flail chest, caused by
extensive segmental rib fractures sustained during cardiopulmonary
resuscitation for a massive pulmonary thromboembolism.%
\end{abstract}%



\sloppy


Title: Use of a pectus bar for surgical stabilization of cardiopulmonary
resuscitation induced flail chest

Running head: Pectus bar insertion for flail chest

Authors: Sung Kwang Lee, M.D., Do Hyung Kim, M.D. Chee Hoon Lee, M.D.

Affiliations: Department of Thoracic and Cardiovascular Surgery, Pusan
National University Hospital, South Korea.

Word count: 1343

Corresponding author: Do Hyung Kim, M.D., Department of Thoracic and
Cardiovascular Surgery, Pusan National University Yangsan Hospital,
Beomeo-ri, Mulgeum-eup, Yangsan, Gyeongsangnam-do, South Korea 626-770,
Tel. +82-55-360-2127, Fax. +82-55-360-2127, E-mail. yumccs@nate.com

Abstract

A flail chest can occur when cardiopulmonary resuscitation causes
extensive rib fractures. Despite successful cardiopulmonary
resuscitation, if the flail chest is not treated, the patient may not
survive regardless of the correction of the primary condition that
caused the cardiac arrest. Therefore, if flail chest persists despite
proper conservative management to correct the flail chest, active
surgical management is essential. We present a successful surgical
treatment with pectus bar for a patient with flail chest, caused by
extensive segmental rib fractures sustained during cardiopulmonary
resuscitation for a massive pulmonary thromboembolism.

Key words: cardiopulmonary resuscitation, flail chest, pectus bar
insertion

Introduction

A flail chest can be caused during cardiopulmonary resuscitation. In
cases where chest wall stability is not achieved with conservative
treatment, active surgical correction becomes essential. Conventional
wide dissection and multiple rib plating are not recommended for
high-risk patients, such as those with pre-existing cardiac conditions.
Therefore, a less invasive and surgically safe alternative is needed.
Recent reports have highlighted the use of a technique using a pectus
bar that was originally used in pediatrics, in patients with severe
trauma to the anterior chest wall. We found this to be an ideal surgical
intervention for such patients.

Case

A 57-year-old woman with Cushing's disease was admitted to the emergency
room with seizure and drowsy mentality. A cardiac arrest occurred during
the observation period and six cycles of cardiopulmonary resuscitation
were performed. The patient was then intubated and underwent mechanical
ventilation, and VA-ECMO insertion, following which CT was performed
that revealed a massive acute pulmonary thromboembolism and intramural
hematoma of aorta (Figure 1). Tissue plasminogen activator infusion was
performed immediately after the diagnosis, but the pulmonary embolism
did not improve and vital signs were difficult to maintain. On the
fourth day of admission, emergency pulmonary thromboembolectomy and
hemi-arch replacement of the aorta were performed.

In the post-operative period, spontaneous breathing was induced to wean
the patient from the mechanical ventilator. However, this failed due to
breathing difficulties accompanied by paradoxical chest movement. Even
after 38 days of positive pressure ventilation, the chest wall
instability did not improve. Since the conservative treatment failed, a
surgical approach was adopted. Chest CT was performed just before the
pectus bar insertion, and bilateral segmental fractures were visualized
from the 2nd to 7th ribs, along with anterior chest wall depression
(Figure 2a). Plating of the 12 segmental fractures was considered
difficult due to the general condition of the patient, and the pectus
bar was surgically inserted under general anesthesia, to maintain
anterior chest wall stability. The lower third of the previous
mid-sternotomy skin incision was re-incised to relieve the adhesions
from the previous surgery, between the anterior chest wall (including
the sternum) and the heart (Figure 2b). After the dissection, a pectus
bar was inserted through 3-cm-long bilateral skin incisions on the chest
(Figure 2c). The surgery was completed after chest stability was
confirmed. Chest CT evaluation on the day after the surgery showed chest
wall elevation and maintenance of the normal rib cage shape by the
pectus bar (Figure 2d). After the surgery, the patient was ventilated
using a portable home ventilator, and respiratory rehabilitation was
performed. The patient was discharged 4 months post-operatively, after
she was able to breathe spontaneously without a respiratory system.

Discussion

Chest compressions performed during cardiopulmonary resuscitation
require the application of strong forces on the chest repeatedly. This
may lead to a number of secondary injuries. Among these, rib fractures
have an incidence of 12.9 to 96.6\% and can result in a flail chest that
presents as a paradoxical chest movement. Autopsy results have reported
the occurrence of flail chest after cardiopulmonary resuscitation to be
common, with an incidence of 14.8\% (1).

When a flail chest occurs, ventilator weaning is often difficult due to
the instability of the respiratory work caused by the paradoxical chest
movement.~If this movement persists before the spontaneous chest wall
stabilization, there can be an additional mechanical impact on the
contused lung area. Therefore, the treatment of flail chest is important
to maintain chest stability. Severe flail chest usually requires
mechanical ventilation with PEEP for 7 to 14 days until the paradoxical
movement disappears. However, prolonged mechanical ventilation can cause
complications such as nosocomial infections and hence, surgical
intervention is essential. Although no significant difference was found
in the mortality rates between surgical and conservative treatments, the
former resulted in reduced pneumonia rate, duration of mechanical
ventilation, and ICU stay (2).

The purpose of the surgical treatment of flail chest is to fix the
fracture site. However, extensive plate fixation is required with a
large incision and wide chest wall dissection. In patients with a
history of cardiac arrest, as was true in the present case, increasing
the risk of surgery by wide dissection and multiple rib and sternum
plating is not desirable. Hence, a less invasive treatment method should
be selected to maintain the chest stability.

Surgical treatment with pectus bar insertion is considered to be one of
the lesser invasive methods for flail chest management and was adopted
for our patient. Pacheco et al. (3) reported the stabilization of severe
flail chest by using four pectus bars in a patient where segmental
fixation was not possible owing to rib fractures. Following this report,
chest wall stabilization using pectus bars was employed for cases that
were impossible to treat by conventional plating methods (4-6). In the
first report, it was used for the purpose of correcting flail chest on
one side of the chest wall; however, recently it has been employed for
bilateral anterior chest walls. Therefore we considered it to be a
suitable treatment for the present case, and it proved to be successful
as evidenced by the chest wall stability observed post-operatively along
with complete respiratory rehabilitation of the patient.

References

1. Akku\selectlanguage{polish}ş \selectlanguage{english}M, Utkusava\selectlanguage{polish}ş \selectlanguage{english}A, Han\selectlanguage{ngerman}özü M, Kaya M, Bakir I. Stabilization of
Flail Chest and Fractured Sternum by Minimally Invasive Repair of Pectus
Excavatum. Thorac Cardiovasc Surg Rep. 2015;4(1):11-3.

2. Schuurmans J, Goslings JC, Schepers T. Operative management versus
non-operative management of rib fractures in flail chest injuries: a
systematic review. Eur J Trauma Emerg Surg. 2017;43(2):163-8.

3. Pacheco PE, Orem AR, Vegunta RK, Anderson RC, Pearl RH. The novel use
of Nuss bars for reconstruction of a massive flail chest. J Thorac
Cardiovasc Surg. 2009;138(5):1239-40.

4. Lee SA, Hwang JJ, Chee HK, Kim YH, Lee WS. Flail chest stabilization
with Nuss operation in presence of multiple myeloma. J Thorac Dis.
2014;6(5):E43-7.

5. Lee SK, Kang do K. Nuss procedure for surgical stabilization of flail
chest with horizontal sternal body fracture and multiple bilateral rib
fractures. J Thorac Dis. 2016;8(6):E390-2.

6. Kim JJ, Kim YH, Moon SW, Choi SY, Jeong SC. Nuss procedure for severe
flail chest after blunt trauma. Ann Thorac Surg. 2015;99(2):e25-7.

Figure legend Figure 1. Chest CT performed immediately after ECMO
insertion showing intramural hematoma of the aorta (yellow arrow) and
massive pulmonary thromboembolism (red arrow) Figure 2. Chest CT
performed just before the pectus bar insertion with three-dimensional
chest wall reconstruction based on the CT data of patients, a) bilateral
segmental fractures were seen from the 2nd to 7th ribs with anterior
chest wall depression, secondary to flail chest. The segmental resection
site is colored blue, b) adhesiolysis (yellow arrow) performed by
re-incising the lower third of the previous mid-sternotomy skin incision
to relieve the adhesions between the anterior chest wall and the heart,
c) pectus bar (green colored bar) was inserted after bilateral 3-cm-long
skin incisions on the chest, d) chest wall elevation and normal rib cage
shape maintained by the pectus bar\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/flail-figure1/flail-figure1}

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\end{figure}\selectlanguage{english}
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\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/flail-figure2/flail-figure2}

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\end{figure}

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