A patient with multiple fractured ribs shows progressive confusion and cyanosis. What is the most appropriate management step?

In a patient with multiple fractured ribs presenting with progressive confusion and cyanosis, the most appropriate management step is endotracheal intubation and mechanical ventilation. This scenario suggests significant respiratory compromise, likely due to the fractured ribs contributing to inadequate ventilation, leading to hypoxia and carbon dioxide retention.

Confusion and cyanosis indicate that the patient is not adequately oxygenating, which could result from impaired lung function caused by pain, limited chest wall movement, or possible underlying pulmonary injury due to the trauma. Endotracheal intubation allows for controlled ventilation, ensuring that the patient receives adequate oxygenation and can effectively eliminate carbon dioxide, thus addressing the immediate life-threatening concerns associated with respiratory failure.

While external stabilization of the chest wall and intercostal nerve blocks may provide pain relief and improve ventilation in the long term, they do not address the acute respiratory failure that is causing the confusion and cyanosis. Intravenous sedation could further depress the respiratory drive, complicating the patient's condition. Therefore, establishing an airway through intubation is the critical step in managing this patient's deteriorating respiratory status efficiently.