• High-flow oxygen should be given through a reservoir mask. • Tracheal intubation and ventilation should be considered immediately if the child is compromised. If ventilation is necessary, it may need to be continued for up to 2 weeks before the flail segment becomes ‘sticky’ and stabilises. On the other hand, minor cases may do well simply with good pain relief and with oxygen by face mask. Nasal or facial continuous positive airway pressure (CPAP), combined with pain relief, may be effective in intermediate cases. • Pain relief should be given using titrated intravenous opioids in the first instance. Local or regional neural blockade avoids the respiratory depressant effects of opioids and should be considered. However, intercostal blocks and epidural catheters are hazardous in the uncooperative patient and sedation may be needed to achieve safety – the risks and benefits of the decision must be carefully considered. Epidural analgesia in children should be carried out by an expert and only after injury to the spine has been ruled out formally. Ca
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