Rosen & Barkin's 5-Minute Emergency Medicine Consult (623 page)

• 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 that increases with deep inspiration, coughing, movement
  
• Pleuritic chest pain
  
• Dyspnea, shortness of breath
  

• Point tenderness
  
• Pain referred to fracture site with palpation of the involved rib elsewhere
  
• Bony step-off
  
• Crepitus
  
• Localized edema
  
• Erythema
  
• Ecchymosis:
  
  • Impact from seat belt, aka “seat belt sign” or steering wheel associated with motor vehicle accidents
    
• Intercostal muscle spasm
  
• Splinting respirations
  
• Hypoxia, tachypnea, respiratory distress
  
• Auscultation shows normal or diminished breath sounds, occasionally an audible click over fracture site.
  
• Segmental paradoxical movement of chest suggests flail chest indicating multiple, unattached fractured ribs.
  

• Diagnosis is initially made on clinical grounds and confirmed on imaging studies.
  
• Evaluate for injury to underlying structures
  

ABGs may reveal hypoxemia or elevated alveolar–arterial gradient:

• Not indicated for simple, uncomplicated rib fractures
  
• May consider in patients with multiple rib fractures or pre-existing pulmonary disease
  

• Anteroposterior (AP) and lateral chest films are used routinely to diagnose rib fractures
  
• Chest radiography is indicated to rule out associated intrathoracic injury but can miss up to 50% of rib fractures:
  
  • May reveal associated intrathoracic pathology:
    
    • Pneumothorax
      
    • Hemothorax
      
    • Pneumomediastinum
      
    • Pulmonary contusion
      
    • Atelectasis
      
    • Widened mediastinal silhouette
      
  • Pulmonary contusion appears within 6–12 hr after injury:
    
    • Ranges from patchy alveolar infiltrates to frank consolidation
      
• Rib radiograph series offer higher sensitivity but are controversial and are often low yield
  
• CT is more sensitive for detecting rib fractures and internal injuries.
  
• CT of the chest may be required to rule out intrathoracic injuries.
  
• CT or US of the abdomen may be required to rule out associated intra-abdominal injuries.
  
• Angiography can be used for the detection of vascular injury if signs and symptoms of neurovascular compromise are present:
  
  • Injury to the 1st and 2nd ribs can be associated with vascular injury, particularly with posterior displacement.
    
• Ultrasound is a promising diagnostic tool for evaluating rib fractures, even for cartilaginous injury
  

• Rib contusion or intercostal muscle strain
  
• Pneumothorax
  
• Costochondral separation
  
• Sternal fracture and dislocation
  
• Nontraumatic causes of chest pain:
  
  • Cardiovascular:
    
    • Myocardial ischemia or infarction
      
    • Pericarditis
      
    • Aortic dissection
      
    • Pulmonary embolism
      
  • Pulmonary:
    
    • Embolism
      
    • Infections
      
    • Inflammation
      
    • Barotrauma
      
  • Musculoskeletal:
    
    • Costochondritis
      
    • Cervical or thoracic spine disease
      
  • GI:
    
    • Esophageal reflux or spasm
      
    • Mallory–Weiss tear
      
    • Biliary or renal colic
      
    • Peptic ulcer disease
      
    • Gastritis, pancreatitis, hepatitis
      
  • Dermatologic:
    
    • Herpes zoster
      
    • Chest wall tumor
      

TREATMENT

Focus on airway maintenance, analgesia, and supplemental oxygen

• For simple fractures, generally no significant stabilization is required.
  
• Multiple fractures, elderly patients, or significant underlying lung disease:
  
  • Manage airway and resuscitate as indicated.
    
  • Endotracheal intubation indicated for patients with severe hypoxemia (PaO
    ₂
    <60 mm Hg on room air, <80 mm Hg on 100% O
    ₂
    ) or impending respiratory failure
    

• Simple fractures:
  
  • Pain control:
    
    • Key to maintaining adequate pulmonary function, avoiding atelectasis and subsequent pneumonia
      
  • Intercostal nerve blocks with 0.5% bupivacaine are safe and effective:
    
    • Provides 6–12 hr of pain relief
      
    • Intercostal nerve block should be performed 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 the intercostal vessels have not been punctured.
      
  • Deep breathing or incentive spirometry should be encouraged with adequate pain control.
    
  • Avoid binders or banding of the chest wall because these restrict ventilation and promote atelectasis.
    
• Multiple fractures, elderly patients, or significant underlying lung disease:
  
  • Pain control and pulmonary toilet
    
  • Search for associated injuries; treat exacerbation of underlying lung disease.
    
  • Intercostal nerve blocks for multiple fractures are safe and effective providing 6–12 hr of pain relief.
    
  • For the admitted patient, thoracic epidural analgesia or patient-controlled analgesia (PCA) is effective, with minimal inhibition of respiratory drive.
    

• 1st Line: NSAIDs with or without opioids
  
  • Ibuprofen: 600 mg PO q6h (peds: 5–10 mg/kg PO q6–8h)
    
  • Naproxen: 250–500 mg PO q12h (peds: 10–20 mg/kg/d PO div. q12h)
    
• Opioid analgesics
  
• Multiple acetaminophen/opioid analgesic combinations are available; see “Alert” below.
  
  • Acetaminophen: 300 mg/codeine 30 mg (peds: 0.5–1 mg/kg codeine) PO q4–6h
    
  • Acetaminophen: 325 mg/hydrocodone 2.5--10 mg PO q4–6h
    
  • Acetaminophen: 325 mg/oxycodone 2.5--10 mg PO q4–6h
    

• 2nd line: For PO intolerance or more severe pain
  
  • Hydromorphone: 2–8 mg PO q3–4h (peds: 0.03–0.08 mg/kg PO q4–6h)
    
  • Hydromorphone: 0.5--4 mg IV/IM/SC q4–6h (peds: 0.03–0.08 mg/kg)
    
  • Morphine sulfate: 2.5–10 mg IV/IM/SC q2–6h (peds: 0.1–0.2 mg/kg)
    
  • PCA using hydromorphone or morphine sulfate is effective.
    
  • Bupivacaine 0.5%: 0.5–1 mL per injection for intercostal nerve blocks
    

FOLLOW-UP

• Intractable pain
  
• Inability to cough and clear secretions
  
• Compromised pulmonary function
  
• Multiple fractures, fractures of the 1st 3 ribs
  
• Displaced rib fractures
  
• Associated pneumothorax, pneumomediastinum, pulmonary contusion, intra-abdominal or intrathoracic pathology
  
• Elderly patients and patients with significant underlying lung disease:
  
  • Chronic COPD, CHF, pulmonary fibrosis, asthma
    
• Inadequate pain control on oral analgesics
  
• ICU care for elderly patients with 6 or more rib fractures
  

• Patients with normal pulmonary function, no underlying pulmonary injury, and adequate pain control on oral analgesics
  
• Strict return criteria should be discussed with the patient prior to discharge:
  
  • Shortness of breath
    
  • Increased pain
    
  • Inadequate pain control
    
  • Fever
    
  • Cough
    

• Most rib fractures heal within 6 wk, but patients should be able to return to regular daily activities much sooner.
  
• Routine follow-up chest x-ray are not recommended
  

• Be vigilant for the underlying intrathoracic and intra-abdominal pathology that can be associated with rib fractures.
  
• Ensuring adequate pain control and ventilation are paramount in the treatment
  
• Each successive rib fracture carries added morbidity and mortality
  
• Pediatric rib fractures imply significant force and should raise suspicion for nonaccidental trauma
  

• Eckstein M, Henderson SO. Thoracic trauma. In: Marx JA, Hockberger RS, Walls RM, eds.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice.
  7th ed. Philadelphia, PA: Mosby Elsevier; 2010.
  
• Kaiser M, Whealon M, Barrios C. The clinical significance of occult thoracic injury in blunt trauma patients.
  Am Surg
  . 2010;76(10):1063–1066.
  
• Livingston DH, Shogan B, John P, et al. CT diagnosis of rib fractures and the prediction of acute respiratory failure.
  J Trauma.
  2008;64:905–911.
  
• Chan SS. Emergency bedside ultrasound for the diagnosis of ribfractures.
  Am J Emerg Med.
  2009;27:617–620.
  

CODES