What is the appropriate evaluation and management of a patient who develops a cough after a fall, considering potential underlying conditions such as rib fractures, pulmonary embolism, or pneumonia?

Cough After a Fall: Evaluation and Management

In a patient who develops a cough after a fall, immediately obtain a chest radiograph to rule out rib fractures, pneumothorax, and pneumonia, as these are potentially life-threatening complications that require urgent intervention. 1

Immediate Assessment Priorities

Rule out life-threatening conditions first:

• Assess for respiratory distress indicators: markedly elevated respiratory rate, intercostal retractions, cyanosis, or altered mental status 2
• Check vital signs including oxygen saturation, respiratory rate, and blood pressure 3
• Evaluate for signs of pneumonia (tachypnea, tachycardia, dyspnea, abnormal lung findings) or pulmonary embolism 1
• Perform focused lung auscultation for wheezing, crackles, or focal findings 3

Essential Imaging Strategy

Chest radiography is the appropriate initial imaging modality:

• Order chest X-ray to evaluate for rib fractures, pneumothorax, pneumonia, or other chest wall abnormalities 1
• Be aware that standard chest radiographs detect rib fractures in only 58% of cases and may miss cartilage injuries, costochondral junction abnormalities, and chest wall soft tissue injuries 1, 4
• If chest X-ray is negative but clinical suspicion remains high (persistent localized pain, palpable crepitus), consider dedicated rib views with radio-opaque skin markers placed at the site of maximal tenderness 1

When to escalate imaging:

• Order chest CT if chest radiograph is negative but you need to evaluate for other pulmonary diseases (pneumonia, pulmonary embolism, pulmonary contusion) 1
• CT with unfolded rib reformats improves diagnostic accuracy for rib fractures and decreases reading time 1
• Consider point-of-care ultrasound for detection of rib fractures if available, as it can detect radiographically occult fractures in 29% of cases 1

Understanding Cough-Induced Rib Fractures

Key clinical features to recognize:

• Cough-induced rib fractures occur primarily in women (78%) with a mean age of 55 years 4
• Chronic cough (≥3 weeks duration) is associated with 85% of cough-induced rib fractures 4
• The most commonly fractured ribs are ribs 6-10, typically along the lateral aspect of the rib cage 4, 5
• Multiple rib fractures occur in 50% of cases, and bilateral fractures occur in 26% 4
• Reduced bone density (osteopenia/osteoporosis) is present in 65% of cases, but fractures can occur with normal bone density 4

Critical Complications to Monitor

Hemothorax is a rare but life-threatening complication:

• Delayed-onset hemothorax can develop even after initial imaging shows only minimal findings 5
• Maintain high suspicion if the patient develops worsening respiratory symptoms, increased pleuritic chest pain, or acute respiratory distress after initial evaluation 5
• Serial monitoring with repeat imaging is essential in patients with rib fractures and persistent or worsening symptoms 5

Other serious complications from rib fractures include:

• Pneumothorax, pulmonary contusion, and pneumonia 1
• Extrathoracic lung herniation through the fracture site (rare but documented) 6
• Respiratory failure requiring mechanical ventilation, particularly with multiple fractures 1, 7

Risk Stratification for Pulmonary Complications

Assess vital capacity if available:

• Every 10% increase in vital capacity is associated with 36% decrease in likelihood of pulmonary complications 7
• Vital capacity <30% is independently associated with pulmonary complications (odds ratio 2.36) 7
• Vital capacity >50% is associated with significantly lower risk of complications 7

Consider surgical stabilization of rib fractures (SSRF) in:

• Flail chest patients 1
• Multiple (≥3) ipsilateral severely displaced rib fractures 1
• Chest wall deformity significantly affecting lung function or showing mechanical instability on palpation 1
• Severe pain non-responsive to multimodal analgesia and loco-regional anesthesia 1

Management of the Cough Itself

Determine cough duration and treat accordingly:

• For acute cough (<3 weeks): Use first-generation antihistamine/decongestant combination plus naproxen if related to upper respiratory infection 2
• For subacute cough (3-8 weeks): Determine if postinfectious or non-infectious; consider upper airway cough syndrome, transient bronchial hyperresponsiveness, asthma, or pertussis 2, 8
• For chronic cough (>8 weeks): Use sequential and additive treatment targeting upper airway cough syndrome, asthma, and gastroesophageal reflux disease 2

Discontinue ACE inhibitors immediately if present, as they cause chronic cough in a significant proportion of patients 2, 3, 8

Common Pitfalls to Avoid

• Don't dismiss normal initial chest radiographs - rib fractures may not be visible on standard views, and complications like hemothorax can develop days later 1, 4, 5
• Don't rely on cough characteristics alone for diagnosis - they have little diagnostic value 1, 2
• Don't assume benign etiology without imaging - serious conditions like pneumonia and pulmonary embolism must be excluded first 1
• Don't use routine cough suppressants when cough clearance is important for preventing pneumonia 2

Follow-Up Instructions

Provide explicit safety-net advice:

• Return immediately if breathing difficulty develops, true hemoptysis occurs, fever develops, or chest pain worsens 3
• Schedule follow-up if cough persists beyond 3 weeks despite treatment 3
• Consider repeat imaging if symptoms worsen or fail to improve, as delayed complications can occur 5