Answer 3
- Order an arterial blood gas evaluation, and admit for observation, incentive
spirometry, and aggressive pulmonary toilet.
Blunt traumatic insult to the
thorax risks damage to both the chest wall and the contained vital structures
(eg, lungs, great vessels, diaphragm, heart, trachea, bronchus, and esophagus).
Aging initiates many changes in respiratory function, including diminished
compliance and elasticity of the chest wall, loss of pulmonary reserve, and a
reduced ability to handle pulmonary secretions. Geriatric patients sustaining
rib fractures suffer twice the mortality and morbidity of younger patients with
similar injuries. It is critical to carefully monitor older patients sustaining
rib fractures with continuous pulse oximetry and early arterial blood gas evaluation.
As a general rule, it is usually prudent to admit the geriatric trauma patient
with 2 or more rib fractures to improve compliance with early ambulation,
incentive spirometry, and aggressive pulmonary toilet. Inspiration typically
aggravates rib fracture pain, prompting splinting and hypoventilation.
In geriatric patients, the pain secondary to rib fractures is likely to
prevent proper ventilation and clearing of secretions by coughing, leading to
atelectasis, retained secretions, and possibly pneumonia; therefore, providing
adequate pain relief alone is crucial, but not sufficient, treatment. Recommended
strategies include oral pain medication, local rib blocks, and epidural analgesia.
Fractures tend to occur at the point of maximal impact posterolaterally, a difficult
area to visualize on plain radiographic films. Binders, belts, and other
restrictive devices should not be used. While decreasing the amount of pain,
these devices promote hypoventilation, increasing the risk for atelectasis and
pneumonia.
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