Dilloted, morphine, Tylenol three

79 female, 1678

Primary health condition:

Rib Fracture (6 broken ribs on right side)

Etiology:

The incidence of rib fractures is dramatically underreported. More than 2 million blunt
mechanisms of injury occur annually just as motor vehicle collisions, with reported incidence of
chest injury between 67 and 70% of those. The prevalence of rib fractures is linked to the
prevalence of the underlying cause of the trauma. Rib fractures are more common in countries
with higher incidence of MVAs. Elderly individuals are more likely to have associated injuries
and complications. Older persons are more prone to rib fractures than younger adults and,
therefore, the pulmonary sequelae such as atelectasis, pneumonia, and respiratory arrest. The
presence of cardiopulmonary disease also significantly increases morbidity and mortality rates in
patients older than 65 years. The clinical benefits of a rib scoring system has been tested at one
site for hospitalized older adults (Melendez, 2017).
Pathogenesis:

Rib fractures may compromise ventilation by a variety of mechanisms. Pain from rib fractures
can cause respiratory splinting, resulting in atelectasis and pneumonia. Multiple contiguous rib
fractures (ie, flail chest) interfere with normal costovertebral and diaphragmatic muscle
excursion, potentially causing ventilatory insufficiency. Fragments of fractured ribs can also act
as penetrating objects leading to the formation of a hemothorax or a pneumothorax. Ribs
commonly fracture at the point of impact or at the posterior angle (structurally their weakest
area). Ribs four through nine (4-9) are the most commonly injured. The thinnest and weakest
portion of the first rib is at the groove for the subclavian artery. The mechanism of first-rib injury
in motor vehicle accidents seems to be a violent contraction of the scalene muscles brought on by
the sudden forward movement of the head and neck. A single blow may cause rib fractures in
multiple places. Traumatic fractures most often occur at the site of impact or the posterolateral
bend, where the rib is weakest (Melendez, 2017). Due to the greater pliability of children's ribs,
greater force is required to produce a fracture (Melendez, 2017).
Clinical Manifestations:

Tenderness on palpation, crepitus, and chest wall deformity are common findings of rib fracture.
Paradoxical chest wall excursion with inspiration is seen with flail chest. A flail chest occurs when a large
segment of ribs is not attached to the spine. These ribs are broken in at least 2 places on each rib. The
paradoxical movement occurs because the middle section of the rib between the 2 fracture sites moves
in response to intrathoracic pressure changes not intercostal muscle contractions. With flail chest, the
detached segment of the chest wall is pulled into the chest cavity during inspiration and pushed
outward during expiration. This abnormal motion increases the work of breathing and compromises
respiratory function, and may necessitate intubation and ventilatory support. Specific signs of
ventilatory insufficiency include cyanosis, tachypnea, retractions, and use of accessory muscles for
ventilation. If fracture of the lower ribs is suspected, assess the patient for abdominal tenderness and
costal margin tenderness, which could raise suspicion for injury to intra-abdominal organs. (Melendez,
Dilloted, morphine, Tylenol three
79 female, 1678

2017). Edema and swelling, muscle spasm, deformity, ecchymosis or contusion, loss of function and
crepitation (Lewis & Dirksen, p.1673, 2018).

Potential Complications:

 pneumonia
 pneumothorax
 hemothorax
 pulmonary contusion
 pain and disability
 aortic injury
 ARDS
 fat embolism
 pulmonary embolism
 non-union of fracture
(Weiser, 2017)
Secondary Health Condition(s):

 hypertension

Surgical History as Applicable:

Unknown (none stated by patient)

Collaborative/Interprofessional Care:

 Diagnostic (History and physical examination , CT scan, MRI, Radiographs)

 Fracture Reduction (Closed reduction, Manipulation, Open reduction, Skeletal traction, Skin
traction)
 Fracture Immobilization (Casting or splinting, external fixation, Internal fixation, Traction)
 Open Fractures (Immobilization, Prophylactic antibiotic therapy, Surgical debridement and
irrigation, Tetanus and diphtheria immunization)

References

https://emedicine.medscape.com/article/825981-clinical#b4

https://www.merckmanuals.com/en-ca/professional/injuries-poisoning/thoracic-trauma/rib-fracture

https://online.epocrates.com/diseases/100934/Rib-fractures/Diagnostic-Tests