Virginia Research Day 2021

CARDIOPULOMNARY RESUSITATION FLAIL CHEST Thomas Garbarino, DO, & Paule � e Bayne-Gaul, DO Sovah Health Internal Medicine Residency Program, Danville, VA P er�ne nt Admission Lab: Hemoglobin 12.1, WBC 7.39, serum crea �nine 0.94, potassium 4.3, glucose 189, albumin 3.1. EKG had sinus tachycardia. Urine drug screen had cocaine. Urinalysis 1+ bacteria, otherwise normal. Normal ini � al portable chest x-ray. Clinical Course : Admi � ed to intensive care unit where stable and then moved to general medic al floor on 3 rd hospital day where he developed shortness of breath and worse, severe chest pain. Follow up chest x-ray and CT demonstrated le � side flail che st (Ribs 3-8). Figures 1 & 2 He was transferred to a t er�a ry care center for video assisted thoracoscopic surgery repair.

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Background: While cardiopulmonary resuscita �on (CPR) is life saving, it c arries signifi cant poten �al morbidity risk. Chief Complaint & History : A 59 -year-old Caucasian male presented to the emergency department a � er cardiopulmonary arrest responding to CPR including naloxone in th e fie ld. Past Medical History: Type 2 diabetes mellitus, chronic low back pain, polysubstance abuse, er ec�le dys func�on , peripheral neuropathy, depression. Medica �o ns : Tadala fil 5mg Dai ly, duloxe �ne 60mg po BI D , gabapen �n 800mg po TI D . Allergies: None Family History : Mother(deceased) had diabetes mellitus and cervical cancer. Otherwise, nega � ve Family History P er�ne nt Review of Systems: Substernal le � -sided pleuri�c che st pain, cough, but no hemoptysis. Vital Signs: . BP 139/73, pulse 102, Resp 17, pulse ox 88% on 6L O2,98.8 F Temp P er�ne nt Physical Findings : Supine alert and oriented obese Caucasian male in moderate distress from substernal and le � che st pain. mild le � anterior chest ecchymosis and tenderness with subcutaneous emphysema and crepitus. Flail chest not appreciated on admission. Social History: Unemployed and permanently disabled from le � lower leg amputa �on. He was independent with a lower leg prosthesis. He has smoked 1/2 pack per day for 40 years, denied alcohol use, but admi � ed to cocaine and marijuana use .

Discussion: Flail chest occurs when 3 or more adjacent ribs fracture in 2 places, crea �ng a flo a �ng segme nt with s o� �ssue s between the ribs. Classically, this unstable sec�on of chest wall exhibits paradoxical mo�on with as pira �on, ho wever, this can be di fficult to detect making the diagnosis o � en di fficult. Flail che st occur s in 5 -13% of pa �e nts 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 pa �e nt did not appear to have. Repair is a di fficult thoracic surgery procedure with o � en extended recovery �me. Postmortem/autopsy cases reviews suggest that fl ail chest injuries are more common sequelae of CPR than previously appreciated, par�cularly in the elderly.

Figure 1 : Subcutaneous emphysema on Hospital D ay 3 A-P Plain Film highlighted in red (not present on admission imaging).

Figure 2 : Extensive subcutaneous emphysema (red outlined areas) noted on Hospital D ay 3 Chest CT. Yellow circle deno �ng displaced(flo a �ng) rib segme nt indica �ng flail chest .

Conclusion: Given the frequent associa �on w ith pulmonary contusion and increased risk of acute respiratory failur e, �me ly diagnosis and management of flai l chest is impera � ve.

References : 1. Naidoo, The Natural History of Flail Chest Injuries, Chinese Journal of Traumatology , Vol. 20, 293-296, Oct 20, 2017. 2. Perera, Flail Chest, StatPearls Publishing , November 21, 2020. 3. Legome, Ini�a l Evalua �on a nd Management of Blunt Thoracic Trauma in Adults, UpToDate , Aug 28, 2020.

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