Case presentation
History
78 y/o female presenting s/p MVC. Pt was transported via helicopter after a dump truck collided into the passenger side of car; no airbags deployed as was in antique car. Patient was restrained driver with lap belt, and was driving ~20 mph. Per EMS, no LOC, HS and A&Ox3 throughout transport. Was given a total of 200mcg of fentanyl enroute. On evaluation, she is endorsing L scapula pain, denies other symptoms. Patient agitated secondary to pain. She was given 0.5mg Dilaudid in the trauma bay and wheeled to CT scan
Physical
Temp: 36.6
HR 75
RR: 26
BP: 153/74
O2: 82% on RA
A: airway intact
B: b/l breath sounds, symmetrical chest expansion, Trachea Midline
C: palpable radial, femoral, PT/DP pulses
D: GSC 14, PERRL, 3mm
General: Alert and oriented x 3, in moderate distress
Head: normocephalic, atraumatic, nontender to palpation no soft tissue swelling, lacerations, or ecchymosis, no blood/discharge from the ears. no maxillofacial deformity
Eyes: Pupils are equal, round and reactive to light, extraocular movements are intact.
Neck: trachea midline, no crepitus, no signs of airway obstruction, hematoma, stridor, or hoarseness
Chest: Normal rate, Regular rhythm, no lacerations or external wounds, non tender to palpation, symmetrical breath rise
Respiratory: CTAB, equal breath sounds
Abdomen: no lacerations or external wounds, non tender to palpation
Pelvis: stable pelvis, nontender to palpation, equal leg length
Extremities: 5/5 strength and full ROM in Bilateral upper and lower extremities. 2+ peripheral pulses, warm and perfused. no pain with passive ROM or palpation
Back: Abrasion and hematoma to L upper back, significant tenderness to palpation
Spine: no midline tenderness to palpation, no swelling, no step- offs, no lack of sensation in extremities
Imaging
Significant findings on CT images: Negative for intracranial hemorrhage, cervical spinal fracture/subluxation. Nondisplaced fractures of anterior right first and second ribs. Fractures of left second through 11th ribs with some of these fractures comminuted and the more inferior left rib fractures markedly displaced. Small left hydropneumothorax.
Rib Fractures
Usually occur following a direct, blunt force to the ribs
Result in splinting, short/shallow breaths, tachypnea, and hypoxia
Most rib injuries due to trauma occur in a midaxillary or posteroaxillary location, where the rib is thinner
Can occur along any rib however injuries to ribs 1, 2, and 3 are less common after trauma and suggest a higher-energy mechanism may have occurred
Diagnostics, Treatments, and Concerns
Diagnostics:
Treatment
multimodal approach to pain management incorporating opioid and nonopioid analgesics, neuraxial blockade, and regional anesthesia on an as needed basis
ketorolac may reduce the risk for pneumonia after rib fracture
low-dose ketamine infusion at a rate of failed to demonstrate improvement in pain scores or opioid requirements
Concerns.
Flail Chest
Definition
three or more adjacent ribs that are fractured at two points, creating a freely moving segment of the chest wall that results in paradoxical motion
As the patient inhales, the intact chest wall moves outward, whereas the flail segment moves inward. As the patient exhales, the opposite occurs
--> ineffective ventilation because of increased dead space, decreased intrathoracic pressure, and increased oxygen demand from injured tissue
What about the O2%?
If the patient remains hypoxic while on supplemental O2 (NC/Venti/NRB), intubation and positive pressure ventilation should be considered and performed
However, continuous positive airway pressure is a potential alternative to endotracheal intubation in patients who require positive pressure ventilation but are appropriate based on clinical suspicion
Non-invasive CPAP with PCA led to lower mortality and a lower nosocomial infection rate, but similar oxygenation and length of ICU stay
References
Gunduz M, Unlugenc H, Ozalevli M, Inanoglu K, Akman H. A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest. Emerg Med J. 2005;22(5):325-329. doi:10.1136/emj.2004.019786
Maher, P. (2021) Emergency department management of Rib Fractures (trauma CME): EB medicine, Rib Fractures: Diagnosis and Management in the Emergency Department. Available at: https://www.ebmedicine.net/topics/trauma/rib-fracture (Accessed: 21 September 2023).
Perera TB, King KC. Flail Chest. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534090/
Wright Angela, Wolf Stephen. Blunt Thoracic Trauma. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recwp71YmuzjjxT8P/Blunt-Thoracic-Trauma#h.n9bih0yq5ezm. Updated March 24, 2023. Accessed September 21, 2023.
Charles Wyatt, MD
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