A 59-year-old woman is brought to the emergency department after falling from a standing height. The patient became lightheaded after rising quickly from bed and fell sideways. She struck her left posterior chest against the nightstand but did not hit her head or lose consciousness. The patient now has left-sided chest and shoulder pain, which is worse with deep breathing. Blood pressure is 102/54 mm Hg, pulse is 114/min, and respirations are 20/min. Oxygen saturation is 96% on room air. On examination, the patient is alert and mildly diaphoretic. The trachea is midline and neck veins are flat. Exquisite tenderness and a palpable step-off are present over the left lower ribs posteriorly. Bilateral breath sounds are normal. Heart sounds are unremarkable. The extremities have symmetric strength and no gross deformities. Chest x-ray reveals displaced fractures of the posterior ninth and tenth ribs. Which of the following is the best next step in management of this patient?

Question

A 59-year-old woman is brought to the emergency department after falling from a standing height.  The patient became lightheaded after rising quickly from bed and fell sideways.  She struck her left posterior chest against the nightstand but did not hit her head or lose consciousness.  The patient now has left-sided chest and shoulder pain, which is worse with deep breathing.  Blood pressure is 102/54 mm Hg, pulse is 114/min, and respirations are 20/min.  Oxygen saturation is 96% on room air.  On examination, the patient is alert and mildly diaphoretic.  The trachea is midline and neck veins are flat.  Exquisite tenderness and a palpable step-off are present over the left lower ribs posteriorly.  Bilateral breath sounds are normal.  Heart sounds are unremarkable.  The extremities have symmetric strength and no gross deformities.  Chest x-ray reveals displaced fractures of the posterior ninth and tenth ribs.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d941_3980_bc81_9f8ca22becea_MD0003_00 This patient's fall resulted in displaced, left-sided lower rib fractures capable of injuring the spleen. In this setting, the patient's tachycardia is concerning for early hemorrhagic shock, and her left shoulder pain (with normal neuromuscular examination) is concerning for referred pain from the left diaphragm. Because of the intimate association between the diaphragm and splenic capsule, a contained splenic bleed can present with referred left shoulder pain prior to the onset of more significant abdominal symptoms. Fractures of ribs 9-12 can injure intraabdominal organs. Unlike hollow viscus injuries, which may show subdiaphragmatic free air on upright x-ray, solid organ (eg, liver, spleen, kidney) injuries are typically not visible on plain abdominal x-ray (Choice E). Therefore, suspicion of intraabdominal organ injury should prompt CT scan of the abdomen, provided that the patient is not hemodynamically unstable (ie, systolic blood pressure <90 mm Hg). The use of IV contrast better visualizes solid organ injury and potentially detects contrast "blush" (extravasation) at the site of bleeding. Focused Assessment with Sonography for Trauma (FAST) would also be a reasonable next step; however, CT scan should be performed whether or not FAST detects free fluid, given the high suspicion for intraabdominal injury. next step (Choice A) CT angiography of the chest can identify injuries to the intrathoracic vasculature. Injuries to major vessels (eg, aorta, subclavian vessels) are more common with fractures of ribs 1-3. (Choice C) A left shoulder x-ray series can diagnose fracture or dislocation. There was no history of direct trauma to the patient's left shoulder, and examination revealed no extremity deformities or decreased strength. This makes left shoulder injury less likely, especially when the patient has a source (ie, ruptured spleen) for referred pain to the left shoulder that may require urgent intervention. (Choice D) Noncontrast CT of the head evaluates for intracranial hemorrhage, especially after head trauma or unexplained loss of consciousness. This patient did not hit her head or lose consciousness when she fell. (Choice F) Transthoracic echocardiography may eventually be obtained to work up this patient's lightheadedness and fall, but evaluation for possible intraabdominal injury takes precedence, particularly because of her normal heart sounds, flat neck veins, and lack of lower extremity edema. Educational objective: Displaced fractures of ribs 9-12 can injure intraabdominal organs, including the spleen. Bleeding that irritates the diaphragm may cause referred pain (eg, to the left shoulder). References: Traumatic rib injury: patterns, imaging pitfalls, complications, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28186860) Western Trauma Association critical decisions in trauma: management of rib fractures. (http://www.ncbi.nlm.nih.gov/pubmed/27779590)

A 59-Year-Old Woman Is Brought to the Emergency Department After