often use their accessory muscles to help with breathing. Lungs sounds are
distant and associated with wheezes, rhonchi, and a prolonged expiratory
phase. These individuals are often classified as “pink puffers” and use their
pursed lips to push air that remains trapped in alveoli owing to the pro-
longed expiratory phase. Exacerbations should be treated with corticos-
teroids, anticholinergic inhalers, and intermittent β 2 -agonists to decrease
inflammation, decrease mucous production, and relax smooth muscle in an
effort to open up the distal airways. Patients with COPD are at higher risk for
developing bacterial bronchitis and pneumonia. COPD is generally caused
by smoking but may also result from air pollution, occupational exposure,
and genetic factors, such as α 1 -antitrypsin deficiency. Patients may require
supplemental outpatient oxygen to function and perform basic activities of
daily living.
Patients with chronic bronchitis (a)are considered “blue bloaters” given
their mucous overproduction that causes hypoventilation. These patients
generally have lowered oxygen saturation levels at baseline. They usually are
stocky in build, have a productive cough, and have a normal AP chest diam-
eter. Asthma (b)is characterized by airway hyperreactivity and inflamma-
tion. It is a reversible process whereas emphysema is not. This patient’s signs
and symptoms are not typical of CHF (d)or pneumothorax (e).
65.The answer is d.(Rosen, pp 381-383.)Given the history of trauma, a
rib fractureis the most probable etiology of the patient’s symptoms in this
clinical scenario. Rib fractures usually occur at the point of impactor at the
posterior angle,which is the weakest part of the rib. It is important to note
that the true danger of rib fractures involves not the rib itself, but the risk of
penetrating injury to underlying structures. A rib seriesis the most effective
way to visualize these fractures. Treatment of patients with simple acute rib
fractures includes pain relief so that respiratory splinting does not occur,
which increases the rate of atelectasis and pneumonia. Chest binders should
not be used as they promote hypoventilation. For multiple rib fractures,
intercostal nerve blocks may be a more effective means of analgesia. Most
rib fractures heal uneventfully within 3 to 6 weeks. The patient should be
encouraged to take deep breaths to avoid developing pneumonia.
A chest radiograph (a)is valuable for investigating other associated
injuries, but often obscures the ribs and fractures may remain hidden.
A chest CT scan (b)is not indicated at this time and is only warranted with
worsening symptoms or negative radiographs with a high clinical suspicion.
An ECG (c)may be obtained to evaluate the general health of this patient but
72 Emergency Medicine