From the Guidelines
For an adult female who fell down four steps and is complaining of tenderness to the right chest, ribs, and right abdomen, I strongly recommend starting with plain radiographs including chest X-ray and right rib series to evaluate for rib fractures, pneumothorax, or hemothorax, as suggested by the American College of Radiology Appropriateness Criteria for rib fractures 1.
Initial Assessment
The initial assessment should include a focused abdominal sonography for trauma (FAST) exam to check for free fluid in the abdomen that might indicate internal bleeding, as well as complete blood count, comprehensive metabolic panel, and urinalysis to assess for anemia, liver or kidney injury, and hematuria.
- The mechanism of injury raises concern for potential liver injury given the right-sided abdominal pain, as the liver is located in the right upper quadrant and is vulnerable to blunt trauma.
- Vital signs should be monitored closely, as hemodynamic instability would necessitate more urgent intervention.
- Pain management should be initiated but balanced with the need to monitor for evolving symptoms that might indicate worsening internal injury.
Further Evaluation
If there is significant abdominal tenderness or the FAST exam is positive, a CT scan of the chest and abdomen with IV contrast would be appropriate to evaluate for solid organ injuries (liver, spleen, kidneys) and to better visualize rib fractures, as supported by the updated European guideline for the management of bleeding and coagulopathy following major trauma 1.
- The use of contrast-enhanced CT scanning can help quickly identify bleeding lesions and obtain a complete picture of all hemorrhagic sources and injuries, expediting the appropriate therapeutic strategy 1.
- The integration of modern MSCT scanners in the emergency room area allows for the immediate assessment of trauma victims following admission, and whole-body CT as a standard diagnostic tool during the earliest resuscitation phase for polytraumatized patients provides the added benefit of identifying head and chest injuries and other bleeding sources in multiply injured patients 1.
From the Research
Initial Assessment
The patient, an adult female, has fallen down four steps and is complaining of tenderness to the right chest, ribs, and right abdomen. Given the mechanism of injury and symptoms, the following studies are warranted:
- Chest X-ray (CXR) to evaluate for pneumothorax, hemothorax, and rib fractures 2, 3, 4
- Abdominal computed tomography (CT) scan to evaluate for intra-abdominal injuries, as tenderness to the right abdomen is present 5
Diagnostic Imaging
The use of CXR as a diagnostic imaging tool in thorax trauma has been evaluated in several studies:
- A study published in 2018 found that CXR had a sensitivity of 39.1% and specificity of 100% for diagnosing pneumothorax, and a sensitivity of 48.8% and specificity of 100% for diagnosing rib fractures 2
- A study published in 2021 found that CXR missed injuries in 54.7% of patients, including 7.7% of major injuries, and had a sensitivity of 75.4% and specificity of 86.2% for injuries of major clinical significance 4
- A study published in 2010 found that an abdominal CT scan identified 65% of occult pneumothoraces, 100% of occult hemothoraces, 64% of occult pulmonary contusions, and 58% of occult rib fractures, suggesting that a CXR and an abdominal CT scan may be sufficient to identify most clinically significant thoracic injuries 5
Management
The management of chest trauma, including rib fractures, pneumothorax, and other injuries, has been reviewed in a 2020 article, which highlights the importance of regional anesthesia techniques and multimodal analgesic strategies in improving patient outcomes and reducing complications 6
- The article also discusses recent changes to recommended management of tension pneumothorax
- The use of paravertebral blocks and myofascial plane blocks as emerging techniques for managing chest trauma is also mentioned 6