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Snapshot
  • A 17-year-old boy presents to the emergency department following a motor vehicle accident 2 hours ago. He is clinically stable but reports trouble breathing and significant pain in his chest. Per the passenger, he hit the steering wheel pretty hard despite the dispatch of airbags. A physical examination demonstrates severe bruising and ecchymosis of the chest area. As the patient inhales, you observe a portion of the chest moving inward. A chest radiograph demonstrates several broken ribs. 
Introduction
  • Clinical definition 
    • occurs when > 2 ribs are broken in > 2 places creating 1 floating segment, usually secondary to significant blunt trauma
      • affected chest wall moves paradoxically to the rest of the chest wall
  • Epidemiology
    • occurs in 5-13% of patients with chest wall injury
    • risk factors
      • motor vehicle collisions (MVCs) is the most common cause
  • Pathogenesis
    • occurs following chest trauma
  • Associated conditions
    • significant morbidity from pulmonary contusion
    • cardiac contusion 
    • aortic dissection 
    • sternal fracture 
    • intra-abdominal injury (e.g., spleen and liver) 
Presentation
  • Symptoms
    • pleuritic chest pain
    • dyspnea
    • hyperventilation
    • dizziness
    • syncope
  • Physical exam
    • paradoxical chest wall movement
      • inward during inhale and outward during exhale
      • may not be appreciated if the patient is splinting with pain
    • crepitus over the defect
Evaluation
  • Diagnostic testing
    • diagnostic approach
      • following initial resuscitation and primary survey, patients are often diagnosed clinically with positive physical examination findings and later confirmed via chest radiograph
    • imaging
      • chest radiograph
        • best initial test
        • allows for evaluation of other conditions of blunt chest trauma (e.g., aortic dissection)
      • ultrasound (e.g, FAST exam)
        • part of the initial trauma evaluation
        • allows for rule out of pneumothorax or hemothorax
        • limited by the operator
      • chest computed tomography (CT)
        • more sensitive test compared to chest radiograph
        • allows for detailed evaluation of intrathoracic structures (e.g., pulmonary contusions and lacerations)
    • studies
      • cardiac and respiratory monitoring (e.g., pulse oximetry and capnography)
Differential
  •  Secondary pneumothorax 
    • distinguishing factor
      • will usually be present on either chest radiograph or chest CT 
  •  Musculocutaneous injury
    • distinguishing factor 
      • paradoxical movement of the chest wall is usually not present 
Treatment
  • Management approach
    • initial management consists of stabilization (e.g., oxygen) with close monitoring for early signs of respiratory compromise 
    • most patients will heal their rib fractures with conservative measures  
  • First-line
    • conservative management 
      • oxygen and monitoring
        • intubation and ventilator support indicated if signs of impending respiratory failure
      • analgesic for pain management
        • opioids
        • intercostal nerve block for severe pain 
      • respiratory toilet and pulmonary care (e.g., incentive spirometry)
      • fluid management to limit pulmonary edema  
  • Second-line
    • surgical management
      • rib fracture fixation indicated in patients with flail chest with respiratory failure requiring mechanical ventilation
      • other indications include significant chest wall deformity, failure to wean from mechanical ventilation, significantly displaced ribs
Complications
  • Pneumonia
    • most common complication
    • prevention via adequate pain control and aggressive pulmonary support
  • Respiratory failure
    • secondary to increased work of breathing and poor pulmonary hygiene
  • Retained hemothorax
  • Empyema
  • Chronic pain secondary to fracture nonunion

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Questions (2)
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(M2.PL.17.4868) A 27-year-old man presents to the emergency department after a motor vehicle accident. He was the unrestrained driver in a head-on collision. The patient is currently unresponsive and his clothes are soaked in blood. The patient is breathing on his own and grimaces in response to pain. His temperature is 99.5°F (37.5°C), blood pressure is 90/60 mmHg, pulse is 130/min, respirations are 19/min, and oxygen saturation is 95% on room air. The patient is started on intravenous fluids. A FAST exam is negative for signs of intra-abdominal trauma. A chest radiograph is within normal limits. Lacerations on the patient’s chest, back, and head are repaired, and the patient is given blood products. Repeat vitals reveal a blood pressure of 110/70 mmHg and a pulse of 90/min. The patient is observed in the trauma bay. Five hours later, his temperature is 99.5°F (37.5°C), blood pressure is 115/75 mmHg, pulse is 85/min, respirations are 23/min, and oxygen saturation is 84% on room air. A chest radiograph is ordered as seen in Figure A. An arterial blood gas is performed and reveals the findings below.

Gases, arterial blood:
pH: 7.56
PCO2: 23 mmHg
PO2: 70 mmHg

Which of the following is the best next step in management?

QID: 109529
FIGURES:
1

Needle decompression in the second intercostal space

14%

(8/56)

2

Placement of a chest tube

30%

(17/56)

3

Sputum culture followed by IV antibiotics

2%

(1/56)

4

Intercostal nerve block

12%

(7/56)

5

Supportive therapy

39%

(22/56)

M 7 D

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