Chest wall injuries in the elderly
An elderly patient attends with a history of a fall onto the chest. They have some chest wall tenderness on the right but are physiologically well. The following CXR was undertaken:
What abnormalities can you see?
What is the optimal management strategy for these?
1. New fractures postero-laterally of the 7th and 8th ribs with some concave deformity of the right chest wall.
2. Blunting of the right costophrenic angle ( likely to represent haemothorax).
3. Multiple surgical clips, ?prev mastectomies/LN clearances.
The elderly are more likely to suffer chest wall injury from falls, but also are more likely to die from them - the OR of death roughly doubles for each of: age >65, multiple comorbidities and >3 fractures. Predictors of poor outcome are fairly well established.
65% of people with a rib fracture on a chest Xray are found to have more if they later have a CT.
Any traumatic haemothorax needs consideration for drainage. Ideally small ones should be ultrasound marked, in line with BTS guidance. Remember, to even blunt the costophrenic angle as above can take 500ml, so don't forget the rest of the ABC....
And of course, if there wasn't a fall to explain it, an effusion in a patient with a mitotic history would have needed urgent investigation.
The trust is shortly to introduce a scoring system for chest wall trauma so that people at higher risk can receive better analgesia (PCA or epidural etc) and also earlier critical care input or high dependency nursing - we'll link to it here once it's formalised, but look out for it.
For pain relief, how about haematoma blocks?
I'm a big fan of haematoma blocks in general, and although I never got a pneumo like that from intercostal blocks, I always found them a bit of a faff. No doubt that we could improve the pain relief for the majority of them though. Nice idea for a study as you say....
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The Derrifoam Blog
Welcome to the Derrifoam blog - interesting pictures, numbers, pitfalls and learning points from the last few weeks. Qualityish CPD made quick and easy.....