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A 22-year-old man is brought to the emergency department after a motor vehicle

collision. Emergency medical responders immobilize his cervical spine, obtain
intravenous access, and start normal saline infusion. In the emergency department, the
patient appears to be in respiratory distress with respirations of 40/min. Pulse is 120/min
and blood pressure is 100/60 mm Hg after receiving 2 L of normal saline over 20
minutes. He develops progressive respiratory failure and receives bilateral chest tubes.
Endotracheal intubation is performed and mechanical ventilation is initiated. Pulmonary
examination reveals bilateral coarse breath sounds. Chest x-ray post intubation is shown
in the image below.

Which of the following is the most likely diagnosis in this patient?

0 A. Diaphragmatic tear
0 B. Esophageal rupture
0 C. Flail chest

.
0 D. Myocardial dysfunction
... . .... - .. . .. .

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intravenous access, and start normal saline infusion. In the emergency department, the
patient appears to be in respiratory distress with respirations of 40/min. Pulse is 120/min
and blood pressure is 100/60 mm Hg after receiving 2 L of normal saline over 20
minutes. He develops progressive respiratory failure and receives bilateral chest tubes.
Endotracheal intubation is performed and mechanical ventilation is initiated. Pulmonary
examination reveals bilateral coarse breath sounds. Chest x-ray post intubation is shown
in the image below.

Which of the following is the most likely diagnosis in this patient?

0 A Diaphragmatic tear
0 B. Esophageal rupture
0 C. Flail chest
0 D. Myocardial dysfunction
0 E. Tension pneumothorax

Subm it
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A 22-year-old man is brought to the emergency department after a motor vehicle

collision. Emergency medical responders immobilize his cervical spine, obtain
intravenous access, and start normal saline infusion. In the emergency department, the
patient appears to be in respiratory distress with respirations of 40/min. Pulse is 120/min
and blood pressure is 100/60 mm Hg after receiving 2 L of normal saline over 20
minutes. He develops progressive respiratory failure and receives bilateral chest tubes.
Endotracheal intubation is performed and mechanical ventilation is initiated. Pulmonary
examination reveals bilateral coarse breath sounds. Chest x-ray post intubation is shown
in the image below.

Which of the following is the most likely diagnosis in this patient?

A Diaphragmatic tear [4%)

B. Esophageal rupture [9%)
C. Flail chest [70%)
D. Myocardial dysfunction [7%)
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Which of the following is the most likely diagnosis in this patient?

A Diaphragmatic tear [4%)

B. Esophageal rupture [9%)
C. Flail chest [70%)
D. Myocardial dysfunction [7%)
0 E. Tension pneumothorax [9%)

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Explanation: User ld

Flail chest

• >3 contiguous ribs fractured in >2 locations

Pathophysiology
- flail chest segment

• Paradoxical chest wall motion with respiration

Findings • Chest pain, tachypnea, rapid shallow breaths
• CXR: Rib fractures +/- contusion/hemothorax

Management • Pain control, supplemental oxygen

• PPV (+/- chest tube) if respiratory failure

CXR = chest x-ray; PPV = positive pressure ventilation.

©UWo~d

This patient with multiple rib fractures (white arrows on chest x-ray) likely has flail
chest. This condition is usually caused by blunt thoracic trauma (eg, steering wheel
hitting the chest in a motor vehicle collision), and describes what occurs when ?!3
adjacent ribs fracture in ?!2 places. The fractured portion of the rib cage (flail
segment) separates from the rest of the chest wall and moves in a paradoxical motion
on respiration. Due to negative intrathoracic pressure during inspiration and positive
intrathoracic pressure during expiration, the flail segment tends to retract inward during
inspiration (versus moving outward with the chest wall) and bulges outward during
expiration (versus retracting inward).

Patients with flail chest present with respiratory distress and tachypnea with shallow
breaths. Muscle attenuate the motion of the flail and
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<DUWorid

This patient with multiple rib fractures (white arrows on chest x-ray) likely has flail
chest. This condition is usually caused by blunt thoracic trauma (eg, steering wheel
hitting the chest in a motor vehicle collision), and describes what occurs when =::3
adjacent ribs fracture in =::2 places. The fractured portion of the rib cage (flail
segment) separates from the rest of the chest wall and moves in a paradoxical motion
on respiration. Due to negative intrathoracic pressure during inspiration and positive
intrathoracic pressure during expiration, the flail segment tends to retract inward during
inspiration (versus moving outward with the chest wall) and bulges outward during
expiration (versus retracting inward).
Patients with flail chest present with respiratory distress and tachypnea with shallow
breaths. Muscle splinting may attenuate the paradoxical motion of the flail segment and
make the diagnosis difficult on physical examination alone. Pain control and
supplemental oxygen are early steps in management. Respiratory failure can occur,
often due to associated pulmonary contusion and resultant collection of edema and
blood in the alveoli (evidenced by the left-sided alveolar opacity on chest x-ray). Acute
respiratory distress syndrome and pneumonia are other potential
complications. Intubation with mechanical positive-pressure ventilation (and chest tube
placement) is often required.
(Choice A) Diaphragmatic tear typically appears on x-ray as an abnormality in the
diaphragmatic shadow, with herniation of abdominal contents into the left pleural
space. The tip of the nasogastric tube is typically seen in the left hemithorax rather than
below the diaphragm (as in this patient).
(Choice B) Esophageal rupture typically presents with subcutaneous crepitus in the
chest and appears on x-ray as a pneumomediastinum (not seen in this patient).
(Choice 0) Myocardial dysfunction may result from myocardial contusion and lead to
cardiogenic pulmonary edema. Bilateral alveolar infiltrates and interstitial markings
would be expected on chest x-ray (not seen in this patient).
(Choice E) Tension pneumothorax can cause respiratory distress, hypotension, and
tachycardia. Tracheal and mediastinal displacement to the contralateral side (yellow
arrow) and radiolucence on the affected side (red arrow) are typical features on chest x-
ray. Lack of improvement with bilateral chest tubes makes pneumothorax unlikely.

Educational objective:
Flail chest should be suspected in patients with multiple rib fractures and respiratory
distress. Classic x-ray findings show multiple rib fractures overlying a lung contusion.

References:

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segment) separates from the rest of the chest wall and moves in a paradoxical motion
on respiration. Due to negative intrathoracic pressure during inspiration and positive
intrathoracic pressure during expiration, the flail segment tends to retract inward during
inspiration (versus moving outward with the chest wall) and bulges outward during
expiration (versus retracting inward).

Patients with flail chest present with respiratory distress and tachypnea with shallow
breaths. Muscle splinting may attenuate the paradoxical motion of the flail segment and
make the diagnosis difficult on physical examination alone. Pain control and
supplemental oxygen are early steps in management. Respiratory failure can occur,
often due to associated pulmonary contusion and resultant collection of edema and
blood in the alveoli (evidenced by the left-sided alveolar opacity on chest x-ray). Acute
respiratory distress syndrome and pneumonia are other potential
complications. Intubation with mechanical positive-pressure ventilation (and chest tube
placement) is often required.
(Choice A) Diaphragmatic tear typically appears on x-ray as an abnormality in the
diaphragmatic shadow, with herniation of abdominal contents into the left pleural
space. The tip of the nasogastric tube is typically seen in the left hemithorax rather than
below the diaphragm (as in this patient).
(Choice B) Esophageal rupture typically presents with subcutaneous crepitus in the
chest and appears on x-ray as a pneumomediastinum (not seen in this patient).
(Choice 0) Myocardial dysfunction may result from myocardial contusion and lead to
cardiogenic pulmonary edema. Bilateral alveolar infiltrates and interstitial markings
would be expected on chest x-ray (not seen in this patient).
(Choice E) Tension pneumothorax can cause respiratory distress, hypotension, and
tachycardia. Tracheal and mediastinal displacement to the contralateral side (yellow
arrow) and radiolucence on the affected side (red arrow) are typical features on chest x-
ray. Lack of improvement with bilateral chest tubes makes pneumothorax unlikely.
Educational objective:
Flail chest should be suspected in patients with multiple rib fractures and respiratory
distress. Classic x-ray findings show multiple rib fractures overlying a lung contusion.

References:
1. The management of flail chest.
2. Predictors of mortality in patients with flail chest: a systematic review.

Time Spent: 8 seconds Copyright © UWorld Last updated: (08/25/2016)

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gmatic injury/rupture

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pneumothorax
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pneumothorax