Rosen & Barkin's 5-Minute Emergency Medicine Consult (274 page)

FOLLOW-UP

• Patients with serious underlying disease, intractable pain, or immunocompromised
  
• Patients with suicidal ideation
  

Patients with uncomplicated fibromyalgia can be managed as outpatients.

Lifestyle modifications:

• Physical exercise should be encouraged:
  
  • Exercise program should be gradual to avoid overexertion and discouragement.
    
  • Aerobic exercise is more beneficial than simple stretching.
    
  • Efficacy not maintained if exercise stops
    
• Good sleep pattern should also be discussed:
  
  • Establishing nightly ritual in preparation for sleep
    
  • Avoiding caffeine-containing beverages or foods in afternoon or evenings
    
• Encourage stress management and coping strategies.
  
• Participation in educational programs (e.g., cognitive-behavioral therapy):
  
  • Improvement is often sustained for months.
    

As fibromyalgia patients can develop acute symptoms, distinguishing between acute and chronic pain is critical.

• Ablin JN, Buskila D, Clauw DJ. Biomarkers in fibromyalgia.
  Curr Pain Headache Rep
  . 2009;13(5):343–349.
  
• Fitzcharles MA, Yunus MB. The clinical concept of fibromyalgia as a changing paradigm in the past 20 years.
  Pain Res Treat.
  2012;2012:184835.
  
• Mease PJ, Choy EH. Pharmacotherapy of fibromyalgia.
  Rheum Dis Clin North Am
  . 2009;35:359–372.
  
• Russell IJ, Larson AA. Neurophysiopathogenesis of fibromyalgia syndrome: A unified hypothesis.
  Rheum Dis Clin North Am
  . 2009;35:421–435.
  
• Williams DA, Schilling S. Advances in the assessment of fibromyalgia.
  Rheum Dis Clin North Am
  . 2009;35:339–357.
  
• Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.
  Arthritis Care Res (Hoboken)
  . 2010;62(5):600–610.
  

CODES

729.1 Myalgia and myositis, unspecified

BASICS

• Free-floating segment of chest wall:
  
  • 3 or more adjacent ribs are fractured in 2 or more places.
    
  • Rib fractures in conjunction with sternal fractures or costochondral separations
    
• The free-floating segment of chest wall paradoxically moves inward during inspiration and outward during expiration.
  
• The principal pathology associated with flail chest is the
  associated pulmonary contusion:
  
  • There is no alteration in ventilatory mechanics owing to the free-floating segment.
    

• Blunt thoracic trauma
  
• Fall from a height
  
• Motor vehicle accident
  
• Assault
  
• Missile injury
  
• Ribs usually break at the point of impact or posterior angle:
  
  • Ribs 4–9 most prone to fracture.
    
  • Weakest point of ribs is 60° rotation from sternum.
    
• Transfer of kinetic energy to the lung parenchyma adjacent to the injury:
  
  • Disruption of the alveolocapillary membrane and development of pulmonary contusion
    
  • Arteriovenous shunting
    
  • Ventilation/perfusion mismatch
    
  • Hypoxemia
    
  • Respiratory failure may result.
    

• Relatively elastic chest wall makes rib fractures less common in children.
  
• Presence of rib fractures implies much higher energy absorption.
  

Much more susceptible to rib fractures:

• Described with low-energy mechanisms
  
• Complicated by osteoporosis
  

DIAGNOSIS

• Blunt thoracic trauma by any mechanism
  
• Mechanism as described by patient, parent, or pre-hospital personnel:
  
  • Seat belt usage
    
  • Steering wheel damage
    
  • Air bag deployment
    
• Localized chest wall pain increases with deep inspiration, coughing, moving
  
• Pleuritic chest pain
  
• Dyspnea
  
• Hemoptysis
  

• Flail chest paradoxically moves inward during inspiration and outward during expiration:
  
  • Can be missed due to muscle spasm and splinting respirations.
    
  • Inspection under tangential light may be useful.
    
• Multiple rib fractures:
  
  • Bony step-offs
    
  • Ecchymosis
    
  • Crepitus
    
  • Edema
    
  • Erythema and tenderness associated with:
    
    • Splinting respirations
      
    • Intercostal muscle spasm
      
    • Dyspnea, tachypnea
      
  • Onset may be insidious, increasing over time.
    
• Cyanosis, tachycardia, hypotension
  
• Auscultation with initially normal breath sounds progressing to wet rales or absent breath sounds
  

Diagnosis is initially made on clinical grounds and then supported by radiographs.

Arterial blood gas analysis:

• May reveal hypoxemia
  
• Elevated alveolar–arterial gradient
  

• Chest radiograph aids diagnosis and prognosis:
  
  • May reveal associated intrathoracic pathology:
    
    • Pneumothorax
      
    • Hemothorax
      
    • Pneumomediastinum
      
    • Pulmonary contusion
      
    • Widened mediastinal silhouette
      
  • Pulmonary contusion appears within 6–12 hr after injury:
    
    • Ranges from patchy alveolar infiltrates to frank consolidation
      
• Thoracic CT is useful in detecting associated intrathoracic injuries not identified on chest radiograph:
  
  • Thoracic CT found to show on average of 3 additional rib fractures compared with plain chest radiographs.
    

• Chest wall contusion or intercostal muscle strain
  
• Costochondral separation
  
• Sternal fracture and dislocation
  
• Radiographic differential diagnosis includes:
  
  • ARDS
    
  • Pulmonary laceration, infarction, or embolism
    
  • CHF
    
  • Pneumonia, abscess, other infectious processes
    
  • Noncardiogenic causes of pulmonary edema
    

TREATMENT

• Positioning the patient with the injured side down can stabilize the involved chest wall:
  
  • Improve ventilation in noninjured hemithorax.
    
• Thoracic trauma with significant mechanism or combined with pre-existing pulmonary disease should be routed to the nearest trauma center.
  

• Manage airway and resuscitate as indicated.
  
• IV line, O
  ₂
  , continuous cardiac monitoring, and pulse oximetry
  
• Control airway:
  
  • Endotracheal intubation
    
  • Indicated for patients with severe hypoxemia (PaO
    ₂
    <60 mm Hg on room air, <80 mm Hg on 100% O
    ₂
    )
    
  • Significant underlying lung disease
    
  • Impending respiratory failure
    

• Maintain adequate oxygenation and ventilation.
  
• Monitor O
  ₂
  saturation and respiratory rate.
  
• In conscious and alert patients, O
  ₂
  administration via face mask is first-line therapy.
  
• If patient cannot maintain a PaO
  ₂
  >80 mm Hg on high-flow oxygen, consider continuous positive airway pressure via mask or nasal bilevel positive airway pressure.
  
• Consider early endotracheal intubation and mechanical ventilation if the above fails:
  
  • Physiologic internal fixation of the flail segment
    
• External fixation or stabilization of the flail segment is not indicated.
  
• Adequate pain control is critical to maintaining adequate pulmonary function:
  
  • Avoid splinting, atelectasis, and pneumonia.
    
• Search for associated injuries and treat exacerbation of underlying lung disease.
  
• Intercostal nerve blocks with 0.5% bupivacaine are safe and effective when performed properly:
  
  • Provides 6–12 hr of pain relief
    
  • Perform intercostal nerve block posteriorly 2–3 fingerbreadths from the vertebral midline.
    
  • Inject 0.5–1 mL just under the inferior surface of the rib where the neurovascular bundle is located.
    
  • Aspirate 1st to be certain that the intercostal vessels have not been punctured.
    
• Prophylactic antibiotics are not indicated.