A 59-year-old man comes to the emergency department after he fell while walking in his yard and struck his right upper chest on a brick. The patient has severe pain in the right upper chest but none elsewhere. He did not hit his head or lose consciousness. Medical history is significant for coronary artery bypass surgery a year ago. Blood pressure is 90/62 mm Hg, pulse is 118/min, and respirations are 20/min. Pulse oximetry is 96% on room air. On examination, the patient appears diaphoretic. There is swelling, bruising, and tenderness to palpation over the right clavicle and right upper chest. Heart and lung sounds are normal; the abdomen is soft and nontender to palpation. After an intravenous fluid bolus is administered, blood pressure improves to 110/64 mm Hg and pulse to 100/min. ECG reveals sinus tachycardia. A plain film chest x-ray is obtained, as shown in the exhibit. Which of the following is the best next step in evaluation of this patient?

Question

A 59-year-old man comes to the emergency department after he fell while walking in his yard and struck his right upper chest on a brick.  The patient has severe pain in the right upper chest but none elsewhere.  He did not hit his head or lose consciousness.  Medical history is significant for coronary artery bypass surgery a year ago.  Blood pressure is 90/62 mm Hg, pulse is 118/min, and respirations are 20/min.  Pulse oximetry is 96% on room air.  On examination, the patient appears diaphoretic.  There is swelling, bruising, and tenderness to palpation over the right clavicle and right upper chest.  Heart and lung sounds are normal; the abdomen is soft and nontender to palpation.  After an intravenous fluid bolus is administered, blood pressure improves to 110/64 mm Hg and pulse to 100/min.  ECG reveals sinus tachycardia.  A plain film chest x-ray is obtained, as shown in the exhibit.  Which of the following is the best next step in evaluation of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d858_aedd_bc81_d7a7a53bc7b4_MD0003_00 This patient with blunt chest trauma (BCT) (eg, striking a brick) has a comminuted, displaced right clavicular fracture. In addition, he has signs concerning for hemorrhagic shock (eg, hypotension, tachycardia, diaphoresis) and subcutaneous bleeding (eg, bruising, swelling) in the right clavicular area and upper chest. This presentation is concerning for fracture-associated injury to the subclavian vessels, which are in close proximity to the clavicle and typically travel beneath its middle third. Even patients with seemingly minor BCT can have serious intrathoracic injury and hemodynamic instability. Consistent with Advanced Trauma Life Support principles, such patients undergo simultaneous resuscitation (eg, intravenous fluid bolus) and evaluation (eg, clinical examination, chest x-ray) to look for life-threatening injuries. Further management then depends on their response to resuscitation: Further management Patients, such as this one, whose condition improves with resuscitation undergo further testing to visualize intrathoracic injuries. Because displaced clavicular fractures can injure the pleura/lung (eg, pneumothorax), subclavian vessels, and/or brachial plexus, they are best evaluated with CT scan of the chest (typically with intravenous contrast). Patients who remain unstable despite resuscitation require operating room thoracotomy. (Choices B, D, and E) This patient has no neck, arm, or abdominal pain or evidence of injury to these areas on examination. Therefore, further studies (eg, neck CT scan, humerus x-rays, abdominal ultrasound) are not immediately indicated and would not take precedence over CT scan of the chest The chest is where this patient's pain, known injuries (eg, displaced clavicular fracture), and most likely source of hemodynamic instability (eg, injured subclavian vessels) are localized. (Choice C) Blunt cardiac injury (BCI) can result in myocardial dysfunction and cardiogenic shock, which echocardiography can evaluate. However, hypotension from cardiogenic shock (ie, pump failure) is less likely to improve with a fluid bolus than hypotension from hemorrhagic shock (eg, from subclavian vessel bleeding). In addition, BCI is more frequently associated with sternal than clavicular fracture and often causes ECG abnormalities (eg, arrhythmia, ST-segment changes), findings not seen in this patient. Educational objective: Patients with seemingly minor blunt chest trauma (BCT) (eg, clavicular fracture) can have serious intrathoracic injury (eg, subclavian vessel injury). Abnormalities on screening tests (eg, chest x-ray) in stabilized patients with BCT should prompt additional studies (eg, CT scan of the chest) to evaluate for intrathoracic injuries. References: Clavicle fracture with intrathoracic displacement. (http://www.ncbi.nlm.nih.gov/pubmed/23937761)

A 59-Year-Old Man Comes to the Emergency Department After He