There is a Fracture

When I see a patient right before anesthetizing them, only a few things give me pause, and chest pain is one of them. On my last call, an older man came in after a motor vehicle accident; he was driving and suddenly lost consciousness, running his car into a pole. As a result of the accident, he also fractured his ankle. He extricated himself from the car and was picked up by EMS and brought to the emergency department. The workup was a little spotty; he had normal labs, including a troponin, and a negative head CT. No chest X-ray was done, though of course there were ankle films. Orthopedics jumped on it and said his open ankle fracture was an emergency. He arrived in the operating room ready for me to anesthetize.

When I spoke with him, he said his ankle wasn't really bothering him, but rather a substernal chest discomfort. He had a rather sizeable bruise as a result of the airbags, but I was concerned. Why did he lose consciousness? Did he have underlying heart disease? Could there have been an aortic injury? Was this pulmonic?

Although it disrupted OR flow and delayed the surgery, we decided to get a chest X-ray and EKG. Both were normal. We still decided against general anesthesia and did a combined spinal-epidural instead, so that the patient would be awake if his chest pain worsened or he had neurologic symptoms. Ultimately, the patient did fine, and post-operative workup was negative. We may never know what caused the accident, but we have to treat it with caution.