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Final clinical long case 67

Created: 15/9/2021
A 60-year-old woman arrives in A&E after a road traffic accident, complaining of right chest and abdominal pain.

Observations and examinations

  • She is hyperventilating, with paradoxical chest wall movement
  • Oxygen saturation 96% with facemask 15 L
  • Heart rate: 120/minute
  • Blood pressure: 80/60 mmHg
  • She is slightly obese, with a body mass index of approximately 30.
  • She has a fractured pelvis and femur.

  • Blood was found in the diagnostic peritoneal lavage. 
  • Chest X-ray: multiple rib fractures and flail segments, no haemothorax, a small pneumothorax in the right apex, chest drain in situ 
  • Bloods: haemoglobin 8.0 g/dl; packed cell volume is low; K+ 3.3 mEq/L, glucose 11 mmol/L ; everything else is normal 
  • Arterial blood gases: PaO2: 33.1 mmHg; base excess 18 mEq/L; pH 7.2 
  • Computed tomography (CT) neck: normal, no fractures

1. Summarise the main problems.
2. Discuss your further assessment and management.
3. Discuss airway management, and the specific concerns about the C-spine and clearing; would you keep the collar on or take it off for operating theatre management?
4. Would you keep the patient intubated at the end of the case, in view of potential painful rib fractures etc?
5. Discuss pain management for rib fractures; discuss the relative merits of thoracic epidural, intercostal blocks and intrapleural blocks.
6. Discuss intensive care unit management issues (including pulmonary contusions etc).
7. Secondary survey: discuss the appropriate timing of orthopaedic surgery.

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