What is the appropriate workup for a patient with rib pain after a Heimlich maneuver for choking?

From the Guidelines

For a patient with rib pain after a Heimlich maneuver, the appropriate workup should begin with a thorough history and physical examination focusing on the chest wall, followed by plain chest radiography as the first-line imaging study to evaluate for rib fractures, pneumothorax, or other complications. Initial evaluation should include assessment of vital signs, oxygen saturation, and examination for point tenderness, crepitus, or deformity over the ribs 1. The American College of Radiology Appropriateness Criteria suggest that standard chest radiographs are usually sufficient for the diagnosis of rib fractures, and further imaging is generally not appropriate unless there is a high clinical suspicion of associated injuries or complications 1.

Some key points to consider in the workup include:

• Assessment of vital signs and oxygen saturation to rule out any immediate life-threatening complications
• Examination for point tenderness, crepitus, or deformity over the ribs to identify potential areas of injury
• Plain chest radiography to evaluate for rib fractures, pneumothorax, or other complications
• Consideration of a CT scan of the chest if the chest X-ray is negative but clinical suspicion remains high, or if there are concerns for associated injuries or complications 1
• Pain management with oral analgesics such as acetaminophen or NSAIDs, and consideration of a short course of oral opioids for severe pain
• Education on deep breathing exercises to prevent atelectasis and pneumonia, and follow-up if symptoms worsen or fail to improve within 1-2 weeks

It's also important to note that the presence and number of rib fractures, as well as the degree of displacement, may carry prognostic significance, and detection of rib fractures by CT may be indicated under certain circumstances, especially if severe injury is suspected 1. However, the increased sensitivity of CT for the detection of rib fractures does not necessarily alter the management or clinical outcomes of patients without associated injuries 1.

In terms of specific imaging modalities, the evidence suggests that chest radiography is the initial imaging modality of choice, and CT may be considered in certain circumstances, such as high clinical suspicion of associated injuries or complications, or if the chest X-ray is negative but clinical suspicion remains high 1.

From the Research

Appropriate Workup for Rib Pain after Heimlich Maneuver

The appropriate workup for a patient with rib pain after a Heimlich maneuver for choking includes:

• Evaluation for potential complications such as rib fractures, gastric or esophagus perforations, pneumomediastinum, aortic valve cusp rupture, diaphragmatic herniation, jejunum perforation, hepatic rupture, or mesenteric laceration 2
• Examination by an experienced physician to assess for serious and life-threatening complications 3
• Consideration of delayed pneumothorax complicating minor rib fracture after chest trauma, especially if the patient presents with subcutaneous emphysema 4
• Imaging studies such as chest X-ray or computed tomography (CT) scan to evaluate for rib fractures, pneumothorax, or other pulmonary complications
• Monitoring for signs of respiratory distress or other complications, such as shortness of breath, chest pain, or abdominal pain

Potential Complications

Potential complications of the Heimlich maneuver that should be considered in the workup include:

• Rib fractures, which can be associated with pneumothorax, hemothorax, or other pulmonary complications 2, 4
• Gastric rupture, which can occur if the maneuver is applied incorrectly 3
• Pneumomediastinum, aortic valve cusp rupture, diaphragmatic herniation, jejunum perforation, hepatic rupture, or mesenteric laceration, which are rare but potentially life-threatening complications 2
• Delayed pneumothorax, which can occur after minor rib fracture and may require close observation or drainage 4

Management

Management of rib pain after a Heimlich maneuver may include:

• Pain management with analgesics or other medications
• Monitoring for signs of respiratory distress or other complications
• Imaging studies to evaluate for rib fractures or other pulmonary complications
• Consideration of operative fixation of rib fractures if the patient has a recalcitrant pleural effusion or other complications 5