Case Presentation & Conclusion
A 65-year-old man with a history of COPD on home oxygen presents to your busy ED with an injury to his right hand from a fall. He states that he was walking across his living room and tripped over the oxygen tubing. As he tried to catch himself on a nearby table, he felt a painful “pop” in his hand. He denies any other injuries or pain, did not hit his head, and had no loss of consciousness or vertigo. In addition to his COPD, he has a history of coronary artery disease, hypertension, and smoking. His vital signs include a normal pulse rate and normal blood pressure. He is breathing 20 times per minute, and his oxygen saturation is 93% on 2 liters of oxygen by nasal cannula (which he uses at home). He has scattered expiratory wheezing, but he appears in no distress. You notice an obvious rotational deformity with localized swelling of his right hand. The remainder of his examination is unremarkable. He is currently experiencing minimal pain at rest, but he is unable to tolerate any movement of his hand. An x-ray shows an angulated fracture of the fifth metacarpal, which will require reduction. His family is concerned about the risks of medication you might consider because of his other medical problems. You are concerned too, since the last thing you want to do is complicate this patient’s care.
As you start to discuss a plan with the patient, a 35-year-old female who was the restrained driver in a front-impact motor vehicle collision arrives. Her airbag deployed, and there was significant damage to her car. The paramedics report tachycardia to 120 beats/minute; her other vital signs are normal. Your examination reveals a young woman in pain, with a patent airway, equal breath sounds, strong distal pulses, and tenderness to palpation in her abdomen. She has a band-like ecchymosis across her chest wall and abdomen, consistent with placement of a seat belt. She is neurologically intact and is able to report that she did not hit her head or lose consciousness. She has no other tenderness or deformities. After reporting a normal fingerstick glucose and negative pregnancy test, the nurse asks you if you would like to order something for pain; the answer is yes, but you consider the risk of lowering her blood pressure or changing her exam findings, and you wonder what the safest strategy might be.
As you are finishing your evaluation, a 55-year-old woman presents after she slipped in the shower and hit her right chest against the bathtub. She has a history of chronic low back pain managed with methadone, and she tells you, “I have a really high pain tolerance.” She has no complaints of pain anywhere else, and she did not hit her head or lose consciousness. She has no vomiting or neck pain, and her back pain is unchanged from her baseline. She has no weakness, numbness, or paresthesias, and she denies bowel or bladder dysfunction. Her only complaint is pain in her right chest, which is pleuritic and reproducible with palpation. Initial vital signs are normal, and the primary and secondary survey reveal no additional abnormalities. She appears comfortable but asks you if she can have something strong for the pain.
Your first patient’s injury required manipulation and splinting, during which you expected increased pain. After immobilization, however, you expected that pain would be more easily controlled. With the patient’s comorbidities, you were concerned about using agents that may cause respiratory depression (opioids, propofol, etc) or additional sympathetic stimulation (ketamine) with the patients history of coronary artery disease. After discussing options with the patient, you decided to administer an ulnar nerve block with ultrasound guidance, using 0.5% bupivacaine. The procedure was successful in creating anesthesia in the region of the patient’s injury without the risks of sedation. You were able to successfully reduce and splint the injury without obligating additional resources to a procedural sedation and recovery. After arranging follow-up and a prescription for a breakthrough pain control medication, the patient was discharged home in a timely fashion.
After establishing hemodynamic stability with your motor vehicle collision patient, you considered the potential for masking serious injuries with analgesia but realized that appropriate pain control has not been shown to contribute to missing serious injuries in this context. After a dose of IV fentanyl, her heart rate normalized and her pain improved, but she still had tenderness with palpation of the left upper quadrant. A CT scan showed a grade II splenic laceration but no other emergent pathology. You consulted a trauma surgeon, who agreed with your plan for admission for observation and pain control.
You recognized that your third patient’s comfortable appearance and normal vital signs did not prove a lack of pain, and with her chronic opioid dependence, adequate pain control could be challenging. You provided an oral dose of oxycodone and acetaminophen and performed an x-ray, confirming the diagnosis of a single rib fracture. There was no evidence of pneumothorax or other significant pulmonary injury. Although her pain was improved after medication, it was still limiting her ability to take full breaths. You discussed an intercostal nerve block to improve her comfort, to which she agreed. After you performed the nerve block, she had improved comfort and was able to breathe more easily. Knowing that the nerve block would provide relief only during the most painful first several hours, you prescribed additional oral pain medication for use at home. You provided an incentive spirometer with appropriate instruction and discharged her with a follow-up plan and return precautions.