A 40-year-old woman is brought to the emergency department by paramedics after a motor vehicle collision. She was driving and wearing a seatbelt when her car was hit by another vehicle from the opposite direction. Her car went off the road and hit a tree. When paramedics arrived at the scene, the patient was noted to have an open femur fracture but was alert and oriented. Her medical issues include hyperlipidemia and mitral valve prolapse with mild regurgitation. She takes no medications. The patient undergoes open reduction and internal fixation of the femur fracture. She receives intravenous fluids and pain control postoperatively. The next morning she experiences left-sided chest discomfort and shortness of breath. Temperature is 37.6 C (99.7 F), blood pressure is 120/70 mm Hg, pulse is 100/min, and respirations are 30/min. Pulse oximetry shows 84% on room air. Physical examination reveals an area of tenderness over the left chest wall where the seatbelt was placed. On pulmonary examination, the patient has rales over the left upper lung. A 2/6 holosystolic murmur is present over the cardiac apex. Laboratory results are as follows:
ECG shows sinus tachycardia with no ST-segment or T-wave changes. Chest x-ray shows irregular opacification predominantly of the left upper lung.
Adequate pain control and supplemental oxygen by nasal cannula is provided and the patient's respiratory distress improves. Pulse oximetry shows 96% on 3 L/min supplemental oxygen. Which of the following is the best next step in management of this patient?

Question

A 40-year-old woman is brought to the emergency department by paramedics after a motor vehicle collision.  She was driving and wearing a seatbelt when her car was hit by another vehicle from the opposite direction.  Her car went off the road and hit a tree.  When paramedics arrived at the scene, the patient was noted to have an open femur fracture but was alert and oriented.  Her medical issues include hyperlipidemia and mitral valve prolapse with mild regurgitation.  She takes no medications.  The patient undergoes open reduction and internal fixation of the femur fracture.  She receives intravenous fluids and pain control postoperatively.  The next morning she experiences left-sided chest discomfort and shortness of breath.  Temperature is 37.6 C (99.7 F), blood pressure is 120/70 mm Hg, pulse is 100/min, and respirations are 30/min.  Pulse oximetry shows 84% on room air.  Physical examination reveals an area of tenderness over the left chest wall where the seatbelt was placed.  On pulmonary examination, the patient has rales over the left upper lung.  A 2/6 holosystolic murmur is present over the cardiac apex.  Laboratory results are as follows:
 ECG shows sinus tachycardia with no ST-segment or T-wave changes.  Chest x-ray shows irregular opacification predominantly of the left upper lung.
Adequate pain control and supplemental oxygen by nasal cannula is provided and the patient's respiratory distress improves.  Pulse oximetry shows 96% on 3 L/min supplemental oxygen.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Patients in whom there is suspicion of significant pulmonary contusion should be admitted to the hospital and monitored for 24-48 hours. In those who develop respiratory symptoms, treatment involves adequate pain control to avoid hypoventilation, as well as supportive care to include pulmonary hygiene (eg, chest physiotherapy, suctioning) and supplemental oxygen and ventilatory support as needed. With adequate support and monitoring, most patients experience resolution of symptoms within 3-5 days. (Choice A) Fluid management goals in patients with pulmonary contusion are somewhat controversial; however, it is generally recommended to maintain patients at or near euvolemia. Diuresis and fluid restriction are not indicated in the absence of overt volume overload. (Choice B) Patients with pulmonary contusion are at increased risk of developing pneumonia; however, prophylactic antibiotics are not indicated. Supportive care, including pain control and pulmonary hygiene, is the best course of management for preventing pulmonary infection. (Choice C) Mechanical ventilation in the form of noninvasive positive pressure or endotracheal intubation is sometimes required for severe pulmonary contusion; however, this patient's symptoms have responded to pain control and supplemental oxygen, and mechanical ventilatory support is not currently indicated. (Choice E) Therapeutic dose heparin infusion is appropriate management for acute pulmonary embolism, but it is not indicated for the management of pulmonary contusion. Educational objective: Pulmonary contusion is best managed with adequate pain control and supportive care to include pulmonary hygiene and supplemental oxygen and ventilatory support as needed. References: Selective management of flail chest and pulmonary contusion. (http://www.ncbi.nlm.nih.gov/pubmed/7125734)

A 40-Year-Old Woman Is Brought to the Emergency Department by Paramedics