A 22-year-old previously healthy man is brought to the emergency department by ambulance after a motor vehicle collision. The patient was unrestrained, and his vehicle sustained significant damage. The patient has anterior chest wall pain and painful respirations. Blood pressure is 110/70 mm Hg, pulse is 110/min, respirations are 18/min, and oxygen saturation is 98% on room air. He is alert and oriented to time, place, and person. Jugular venous pressure is normal. Anterior chest wall bruising is present. Bilateral breath sounds are normal and equal; heart sounds are normal. Examination of the abdomen and upper and lower extremities shows no abnormalities. Extended Focused Assessment with Sonography for Trauma (eFAST) reveals no pericardial or pleural effusion, or intrabdominal bleeding; chest x-ray and CT scan of the cervical spine are normal. The patient's pain improves with pain medication. Which of the following is the best next step in management of this patient?

Question

A 22-year-old previously healthy man is brought to the emergency department by ambulance after a motor vehicle collision.  The patient was unrestrained, and his vehicle sustained significant damage.  The patient has anterior chest wall pain and painful respirations.  Blood pressure is 110/70 mm Hg, pulse is 110/min, respirations are 18/min, and oxygen saturation is 98% on room air.  He is alert and oriented to time, place, and person.  Jugular venous pressure is normal.  Anterior chest wall bruising is present.  Bilateral breath sounds are normal and equal; heart sounds are normal.  Examination of the abdomen and upper and lower extremities shows no abnormalities.  Extended Focused Assessment with Sonography for Trauma (eFAST) reveals no pericardial or pleural effusion, or intrabdominal bleeding; chest x-ray and CT scan of the cervical spine are normal.  The patient's pain improves with pain medication.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d832_890b_bc81_55405b07c380_MD0003_00 This patient involved in a high-risk (eg, significant damage) motor vehicle collision (MVC) has anterior chest wall pain and tenderness, concerning for blunt chest trauma. He is hemodynamically stable and his chest x-ray and extended Focused Assessment with Sonography for Trauma (eFAST) are normal. The next step is to obtain an ECG to screen for blunt cardiac injury (BCI). For patients with blunt chest trauma, hemodynamic stability or instability determines the management strategy. Hemodynamically unstable patients undergo simultaneous resuscitation and evaluation (eg, chest x-ray, eFAST, ECG) to look for life-threatening injuries. Stabilizing interventions are performed for any abnormalities identified (eg, chest tube for pneumothorax). In stabilized patients, additional tests (eg, chest CT scan) are obtained to assess for further injuries that could be missed on initial evaluation (eg, aortic injury). Patients who remain unstable are taken directly for operating room thoracotomy. In hemodynamically stable patients, the extent of workup is determined by the mechanism of injury and initial examination. Patients without high-risk mechanism and with no serious injuries on examination (eg, normal heart and lung sounds) undergo ECG and chest x-ray. In patients with abnormal findings, interventions are performed (eg, chest tube for pneumothorax) and additional tests (eg, chest CT scan) are obtained, whereas patients without abnormalities can be safely discharged with analgesics and detailed return precautions (Choice C). Patients such as this one who are hemodynamically stable but have a high-risk mechanism (eg, unrestrained; vehicle with significant damage) or those who have serious injury on examination should be treated similarly to hemodynamically unstable patients. Therefore, in addition to eFAST and chest x-ray, this patient should have an ECG performed. ECG can help evaluate for BCI, which most commonly occurs due to rapid deceleration with MVCs and can cause tamponade or wall rupture or be clinically silent. Sinus tachycardia, arrhythmia, or ST changes may be seen. Abnormal ECG is followed by observation for approximately 24 hours (eg, risk of fatal arrhythmias), in addition to cardiac enzyme testing and echocardiography (eg, rule out tamponade) (Choice B). (Choice A) BCI frequently causes sinus tachycardia; however, beta blockers, which reduce both heart rate and myocardial contractility, are not routinely administered because BCI also often causes myocardial edema with decreased contractility, which can lead to hypotension. In addition, sinus tachycardia is often a physiologic response that should be managed by addressing the underlying cause rather than by beta blockade (which blunts the response). (Choice E) Transesophageal echocardiography is useful to evaluate unstable patients for thoracic aortic injury without having to move them to the CT scanner. Educational objective: Patients with blunt chest trauma may be at risk for serious intrathoracic injury. Evaluation includes chest x-ray and ECG. Additional tests/interventions are based on the patient's hemodynamic stability, mechanism of injury, and initial test findings. References: Blunt cardiac trauma review. (http://www.ncbi.nlm.nih.gov/pubmed/29173678)

A 22-Year-Old Previously Healthy Man Is Brought to the Emergency