Virginia Research Day 2021

Medical Resident Research Case Reports

26 Cardiopulmonary Resusitation Flail Chest

Thomas Garbarino, DO; Paulette Bayne-Gaul, DO Corresponding author: michael.moore1@LPNT.net

SOVAH Health Internal Medicine Residency Program

Context: While cardiopulmonary resuscitation (CPR) is lifesaving, it carries significant potential morbidity risk. Case Report: A 59-year-old Caucasian male presented to the emergency department after cardiopulmonary arrest responding to CPR including naloxone in the field. Pertinent Review of Systems: Substernal left- sided pleuritic chest pain, cough, but no hemoptysis. Past Medical & Surgical History (Hx): Type 2 diabetes mellitus, chronic low back pain, polysubstance abuse, erectile dysfunction, peripheral neuropathy, depression. Meds: Tadalafil 5mg daily, duloxetine 60 mg po BID, gabapentin 800 mg po TID. Social Hx: Unemployed and permanently disabled from left lower leg amputation. He was independent with a lower leg prosthesis. He has smoked 1/2 pack per day for 40 years, denied alcohol use, but admitted to cocaine and marijuana use.

Pertinent Physical Exam Findings: Supine, alert, oriented obese Caucasian male in moderate distress from substernal and left chest pain. BP 139/73, pulse 102, Resp 17, pulse ox 88% on 6L O2, Temp 98.8 F, mild left anterior chest ecchymosis and tenderness with subcutaneous emphysema and crepitus. His flail chest was not appreciated on admission. Pertinent Labs: Hemoglobin 12.1, WBC 7,390, serum creatinine 0.94, potassium 4.3, glucose 189, albumin 3.1, EKG had only sinus tachycardia, urine drug screen had cocaine. Urinalysis: 1+ bacteria, otherwise normal. Initial Portable Chest X- ray had no acute cardiopulmonary disease. Treatment: Admitted to intensive care where he received ketorolac intravenously for pain, duloxetine 60 mg p.o. b.i.d., gabapentin 800 mg p.o. t.i.d., lidocaine patch, GI cocktail for epigastric pain and albuterol/ipratropium inhaler with incentive spirometry. He was transferred to a regular ward on the 3rd hospital day. However, he developed worsening shortness of breath and more severe chest pain. A chest CT revealed a left sided flail chest (Ribs 3 – 8).

He was transferred to a tertiary care center for video assisted thoracoscopic surgery repair. Diagnosis: CPR traumatic flail chest with diffuse subcutaneous emphysema. Comments: Flail chest occurs when 3 or more adjacent ribs fracture in 2 places, creating a floating segment with soft tissues between the ribs. Classically, this unstable section of chest wall exhibits paradoxical motion with aspiration, however, this can be difficult to detect making the diagnosis often difficult. Flail chest occurs in 5-13% of patients with chest wall injury most commonly from an automobile accident or high-level fall, but also with about 10% of CPR sessions. Classically, there is an associated pulmonary contusion which our patient did not appear to have. Repair is a difficult thoracic surgery procedure with often extended recovery time. Conclusion: Given the frequent simultaneous pulmonary contusion and increased risk of acute respiratory failure, timely diagnosis and management is imperative.

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