Critical Care Medicine-Pulmonary Disorders>>>>>Diseases of the Chest Wall
Question 4#

A 77-year-old male presented to the emergency department after motor vehicle accident. On arrival, respirations were shallow and the right chest appeared to move inward with inspiration. O2 saturation was 85% while breathing room air and pulse was 122. Chest x-ray and chest CT are shown in the figure below.

What is the next most appropriate step in management?

A. Noninvasive positive pressure ventilation and IV morphine
B. Evaluation for surgical fixation of rib fracture
C. Intubation and adjustment of PEEP to improve oxygenation
D. Epidural catheter placement to decrease splinting

Correct Answer is C

Comment:

Correct Answer: C

The patient has suffered significant thoracic trauma as the result of a motor vehicle collision. He has multiple right-sided rib fractures on CXR and flail chest on exam. In addition, the chest CT scan reveals significant pulmonary contusion and atelectasis. Management of flail chest includes pain control, management of pulmonary injury, and, in selected patients, surgical fixation. Importantly, this patient presents in respiratory distress with evidence of pulmonary contusion on chest CT. There are small trials of noninvasive ventilation in chest injury, but in this patient with distress and established lung injury this would not be appropriate. In addition, IV analgesia carries the risk of respiratory depression. Locoregional (epidural, paravertebral) analgesia is often preferred. There is increasing interest in surgical fixation of flail chest, but in patients with underlying contusion there is no benefit over nonoperative management. Epidural catheter placement can be a key component of pain control in flail chest but does nothing to treat the pulmonary contusion which is likely a larger risk factor for mortality. 

References:

  1. Majercik S, Pieracci F. Chest wall trauma. Thorac Surg Clin. 2017;27:113- 121.
  2. Kiraly L, Schreiber M. Management of the crushed chest. Crit Care Med. 2010;38:S469-S477.