How do you manage a patient with a chest wall injury, broken ribs, and respiratory distress?

Management of Chest Wall Injury with Broken Ribs and Respiratory Distress

For patients with chest wall injury, broken ribs, tachypnea, and respiratory distress, immediate management should include airway maintenance, oxygen supplementation, pain control, and consideration for surgical stabilization of rib fractures in cases of flail chest or severe displacement. 1

Initial Assessment and Stabilization

• Airway and Breathing:

  • Ensure patent airway and provide supplemental oxygen to maintain adequate oxygenation
  • Consider non-invasive ventilation (NIV) for patients with acute respiratory failure as it decreases mortality, reduces intubation need, and lowers pneumonia incidence 1
  • Monitor for signs of deteriorating respiratory status requiring intubation

• Diagnostic Evaluation:

  • Obtain CT scan of the chest to evaluate:
    • Number of fractured ribs
    • Displacement of fractures
    • Presence of flail chest
    • Anatomic distribution of fractures
    • First rib fractures (associated with vascular injuries)
    • Associated injuries (pneumothorax, hemothorax, pulmonary contusion) 1
  • Use contrast-enhanced CT if high-energy mechanism or suspicion of intrathoracic/intra-abdominal injury 1
  • Apply the RibScore to predict adverse pulmonary outcomes based on CT findings 1

Pain Management Algorithm

1. First-line treatment:

   • Regular intravenous acetaminophen (1 gram every 6 hours) 1

2. If pain persists:

   • Add NSAIDs with caution, considering potential adverse events and drug interactions 1

3. For moderate to severe pain:

   • Use opioids at lowest effective dose for shortest possible duration (hydromorphone preferred over morphine) 1
   • Consider ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids 1

4. Regional anesthesia techniques for refractory pain:

   • Thoracic epidural
   • Paravertebral blocks
   • Erector spinae plane blocks
   • Serratus anterior plane blocks 1

Management of Specific Injuries

Flail Chest

• Control paradoxical movement of the chest wall immediately 2
• Maintain airway patency and adequate oxygen supply 2
• Correct respiratory and circulatory dysfunction 2
• For limited or posterior softening chest wall, apply local pad as pressure dressing 2
• For severe paradoxical movement (3-5 cm), apply temporary pressure dressing with pads, then fix chest with multi-head chest strap 2
• Consider surgical stabilization of rib fractures (SSRF) for patients with flail chest and respiratory failure 1

Massive Hemothorax

• Perform tube thoracostomy (chest tube placement) in the fourth/fifth intercostal space in the midaxillary line 2
• Monitor for signs of shock and provide appropriate fluid resuscitation

Pneumothorax

• For open pneumothorax, use breathable chest pad to close the wound 2
• Monitor closely for signs of tension pneumothorax (progressive hypoxia, respiratory distress, hypotension) 2
• If tension pneumothorax develops, remove chest pad or perform needle thoracentesis for decompression 2

Surgical Intervention Criteria

Consider surgical stabilization of rib fractures (SSRF) for:

• Flail chest with respiratory failure
• ≥3 severely displaced rib fractures
• ≥5 consecutive rib fractures 1

Early SSRF (≤48 hours) is associated with:

• Decreased ICU length of stay
• Shorter overall hospital stay
• Fewer ventilation days
• Lower costs compared to delayed fixation 1

Admission Criteria and Monitoring

• ICU admission indicated for:

  • ≥3 rib fractures in elderly patients (>60 years)
  • Flail chest
  • Significant respiratory compromise
  • Poor functional respiratory status (FVC <50% predicted) 1

• Monitor for complications:

  • Pneumothorax
  • Hemothorax
  • Pulmonary contusion
  • Pneumonia
  • Respiratory failure
  • Vascular injuries (especially with first rib fractures) 1

Follow-up Care

• Initial follow-up within 1-2 weeks of discharge for surgical patients
• All patients should have clinic follow-up within 2-3 weeks to evaluate:
  • Pain control
  • Respiratory function
  • Functional status
  • Need for additional imaging 1

Special Considerations

• Patients with underlying respiratory disease or COVID-19 require closer monitoring due to higher risk of respiratory compromise 1
• Elderly patients (>60 years) with ≥3 rib fractures are at higher risk for complications and should receive more aggressive management 1
• Concurrent traumatic brain injury increases risk of poor outcomes 1