A 50-year-old man sustains blunt chest trauma. Three consecutive right ribs are each fractured in two places, producing a paradoxically moving segment of the chest wall. He is breathing spontaneously with an oxygen saturation of 94% on room air and good analgesia has not yet been given. What is the most important initial step in his management?

• A Immediate surgical fixation of the fractured ribs with plates
• B Aggressive IV fluid loading to improve pulmonary compliance
• C Prophylactic positive pressure ventilation via endotracheal intubation
• D Effective analgesia to allow deep breathing and coughing ✓

Explanation

The morbidity of flail chest comes mainly from underlying pulmonary contusion and pain-limited ventilation, not from the rib segment itself. The cornerstone of management is effective analgesia (intercostal blocks, epidural, or systemic opioids) so the patient can breathe deeply and clear secretions, which prevents atelectasis and pneumonia. Surgical fixation is reserved for selected cases such as failed conservative management or severe chest wall instability. Intubation and mechanical ventilation are reserved for respiratory failure, not applied prophylactically in a patient maintaining saturation.

Reference: ATLS Student Course Manual, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.