A previously healthy 45-year-old woman is brought to the emergency department after she slipped and fell backward down half a flight of stairs. She did not hit her head or lose consciousness. The patient has right-sided back and chest pain. Blood pressure is 138/88 mm Hg, pulse is 88/min, and respirations are 24/min. Oxygen saturation is 98% on room air. On physical examination, the patient is alert and taking shallow breaths. Breath sounds are symmetric and heart sounds are normal. The right posterior chest wall is tender to palpation, without crepitus or bony step-offs. Chest x-ray reveals a minimally displaced, posterior fracture of the right sixth rib and bilateral basilar atelectasis, with no pneumothorax or pleural effusion. Which of the following is most essential for preventing pulmonary complications in this patient?

Question

A previously healthy 45-year-old woman is brought to the emergency department after she slipped and fell backward down half a flight of stairs.  She did not hit her head or lose consciousness.  The patient has right-sided back and chest pain.  Blood pressure is 138/88 mm Hg, pulse is 88/min, and respirations are 24/min.  Oxygen saturation is 98% on room air.  On physical examination, the patient is alert and taking shallow breaths.  Breath sounds are symmetric and heart sounds are normal.  The right posterior chest wall is tender to palpation, without crepitus or bony step-offs.  Chest x-ray reveals a minimally displaced, posterior fracture of the right sixth rib and bilateral basilar atelectasis, with no pneumothorax or pleural effusion.  Which of the following is most essential for preventing pulmonary complications in this patient?

Quizplus · Accepted Answer

This patient has an isolated rib fracture without evidence of chest wall deformity or internal organ injury (eg, pneumothorax). Even in the absence of concomitant injuries, rib fractures can cause sufficient pain to result in shallow breathing (ie, small tidal volumes) and atelectasis. Without adequate pain control, splinting and atelectasis increase the risk of pneumonia, a frequent complication of rib fracture. After significant associated injuries have been ruled out or treated, the mainstay of rib fracture management is pain control to ensure appropriate ventilation and adequate cough. Oral nonsteroidal anti-inflammatory drugs (eg, ibuprofen, ketorolac) and opioids are commonly used. Opioids can cause central respiratory depression, but this disadvantage is typically outweighed by the benefits of adequate pain control. For patients who require hospitalization (eg, for more extensive rib fractures), intravenous analgesics and regional anesthetic techniques (eg, epidural infusion, intercostal nerve blocks) may be added. In addition to pain control, patients should be taught the importance of pulmonary toilet and the use of incentive spirometry. (Choice B) This patient's basilar atelectasis (ie, lower lung collapse) on x-ray is likely due to insufficient inspiratory effort from pain; deep breathing (ie, providing adequate inspiratory volume) can reexpand the collapsed lung and resolve the atelectasis. In contrast, continuous positive airway pressure provides gentle pressure to prevent repetitive upper airway collapse/obstruction (eg, obstructive sleep apnea); it would not provide enough pressure to reexpand large segments of collapsed lung. (Choice C) Inhaled bronchodilators decrease airway resistance and improve airflow for patients with reactive airways (eg, asthma). This patient has no evidence (eg, wheezing) of reactive airways. (Choice D) Percussive chest physiotherapy can loosen thick secretions in the lungs to facilitate removal by coughing. Although this patient would benefit from pain control to ensure adequate cough, there is no evidence of thick secretions that require percussive physiotherapy; in addition, this technique likely would be extremely painful in the setting of rib fracture. (Choice E) Although rib fractures can be complicated by pneumonia, prophylactic antibiotics are not routinely indicated. (Choice F) Rib fractures typically heal without surgery, especially nondisplaced fractures, like this patient has. Surgical fixation is typically indicated only for severe cases (eg, flail chest with failure to wean from the ventilator, significant chest wall deformity). Educational objective: Adequate pain control is the mainstay of rib fracture management to prevent the associated complications of atelectasis and pneumonia. 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 Previously Healthy 45-Year-Old Woman Is Brought to the Emergency