What should be performed first in a respiratory distress case with flail chest?

In a case of respiratory distress with flail chest, positive pressure ventilation is critical and should be performed first. Flail chest occurs when multiple adjacent ribs are fractured in multiple places, causing a segment of the chest wall to become detached and move independently during breathing. This can severely compromise the patient's ability to breathe effectively by disrupting normal chest mechanics.

Administering positive pressure ventilation helps to stabilize the thoracic cavity and ensure that adequate ventilation is achieved despite the presence of the flail segment. This intervention allows for the delivery of oxygen and assists in removing carbon dioxide, which is essential given the compromised respiratory function.

While splinting the chest and other interventions like oxygen supplementation and chest tube insertion may also be necessary, they should come after ensuring that the patient is receiving adequate ventilation. Oxygen supplementation serves to correct hypoxia but does not address the underlying mechanics of breathing that are disrupted by flail chest. Thus, establishing effective ventilation with positive pressure is the priority to protect the patient's airway and ensure adequate gas exchange.