Authors: Mark M. Ramzy, DO, EMT-P (@MarkRamzyDO, EM Resident Physician, Drexel University, Department of Emergency Medicine) and Richard J. Hamilton, MD (EM Chair, Drexel University, Department of Emergency Medicine)// Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)
Case

A 39-year-old male presents to the emergency department with shortness of breath and chest pain. Patient states he was assaulted three days ago with a punch to the chest, he suffered no head trauma or loss of consciousness. He was evaluated at another hospital immediately following the assault where a chest x-ray was performed, he is unable to recall the results. He was subsequently discharged from that hospital. Today he describes his centrally located chest pain as non-radiating, sharp, and pleuritic. Pertinent positives on physical exam include the following: anxious-appearing African American male in mild distress. The breath sounds on the upper left chest are decreased. There is point tenderness over the left anterior and lateral chest wall. Vital signs: BP 118/75, HR 96, RR 24, SpO2 88% on room air.
This patient’s clinical presentation and history raise many questions. Several of the diagnoses that emergency physicians are concerned about can often be answered by a good history. Unfortunately, the above patient is not a very good historian, leaving us to rely on our physical exam findings and clinical judgement skills. This post will focus on both threatening and non-threatening pulmonary conditions that may arise from blunt trauma to the chest. Furthermore, it will provide pearls and pitfalls for each condition that will enhance your ability to evaluate a patient with blunt injury to the chest.
 
Rib Fractures

Rib fractures, though often minor, can be an indication of a potentially more serious internal injury with significant associated structural and vascular complications. When considering the diagnosis of rib fracture in a patient, think of the following pearls and pitfalls:
Pearls
50/50 Rule (part 1):50% of patients admitted to the hospital following chest trauma are diagnosed with rib fractures.

Due to their short length, a considerable amount of force is required to fracture the first and second ribs.1

If you’re having difficulty appreciating a lateral rib fracture on a chest x-ray (CXR), try rotating it 90° with the concerning side pointing upwards. Because this breaks up the usual chest radiograph pattern that your brain is accustomed to, your vision does a better job of “seeing” each rib as it is, rather than defaulting to a normal interpretation.

Case Continued

Following our exam, the patient was placed on 3 liters of oxygen via nasal cannula. His dyspnea continued, and his oxygen saturation only improved to 90% after 5 minutes. He was then switched to 10 liters of oxygen via non-rebreather. Given the shortness of breath and point tenderness over the left anterior and lateral chest wall, a chest x-ray was ordered and interpreted using some of the pearls above.

Pitfalls
50/50 Rule (part 2): Within the first few days following an injury, 50% of rib fractures are not seen on a CXR.2

With multiple lower rib fractures, particularly ribs 9-12, it is important to consider intra-abdominal bleeding often from a liver or spleen laceration.

Elderly patients with multiple rib fractures may have difficulty clearing secretions and should be closely monitored for airway compromise.

 
Pulmonary Contusion

Most commonly caused by significant blunt injury to the chest wall following high speed motor vehicle crashes, pulmonary contusions and their complications can be associated with severe mortality and morbidity. 


#Radiology #CTChest #Lung #Pulmonary #Contusion