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Summary of the Day

Optimizing Pediatric Intubation

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Question of the Day

A 22-year-old man presents to the emergency department with multiple rib fractures following a motor vehicle accident. On physical examination, a section of the patient’s chest wall appears to move inward during inspiration. Vital signs include the following: HR 123 bpm, BP 100/62 mmHg, RR 44 bpm, and SpO2 85% on 10 L/min oxygen by face mask. Which of the following is the MOST appropriate intervention?

Question of the Day
A 22-year-old man presents to the emergency department with multiple rib fractures following a motor vehicle accident. On physical examination, a section of the patient’s chest wall appears to move inward during inspiration. Vital signs include the following: HR 123 bpm, BP 100/62 mmHg, RR 44 bpm, and SpO2 85% on 10 L/min oxygen by face mask. Which of the following is the MOST appropriate intervention?
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Correct Answer

Explanation

Flail chest syndrome occurs following trauma to the chest wall with 4 or more adjacent rib fractures in 2 or more places leading to separation of the fractured chest wall section from the rest of the thorax. During spontaneous ventilation, the flail section of the chest wall moves inward on inspiration and then moves outward during expiration leading to decreased tidal volumes and ineffective gas exchange. In addition, patients who suffer from flail chest often have an underlying pulmonary contusion, pneumothorax, or hemothorax that requires specific treatment. This patient is hypoxic despite 10 liters of oxygen delivered by face mask. Treatment is necessary in order to improve oxygenation with either intubation and mechanical ventilation or noninvasive positive pressure ventilation. Positive pressure ventilation is effective in restoring adequate tidal volumes in patients with flail chest by preventing the inward movement during inspiration. A chest tube will not improve oxygenation or pulmonary function and is not indicated. The patient is not hypotensive and neither epinephrine nor vasopressin would improve the patient’s oxygenation.

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