New horizons in rib fracture management in the older adult

Abstract Adults aged ≥60 years now represent the majority of patients presenting with major trauma. Falls are the most common cause of injury, accounting for nearly three-quarters of all traumas in this population. Trauma to the thorax represents the second most common site of injury in this population, and is often associated with other serious injuries. Mortality rates are 2–5 times higher in older adults compared to their younger counterparts, often despite equivalent injury severity scores. Risk scoring systems have been developed to identify rib fracture patients at high risk of deterioration. Overall mortality from rib fractures is high, at approximately 10% for all ages. Mortality and morbidity from rib fractures primarily derive from pain-induced hypoventilation, pneumonia and respiratory failure. The main goal of care is therefore to provide sufficient analgesia to allow respiratory rehabilitation and prevent pulmonary complications. The provision of analgesia has evolved to incorporate novel regional anaesthesia techniques into conventional multimodal analgesia. Analgesia algorithms may aid early aggressive management and escalation of pain control. The current role for surgical fixation of rib fractures remains unclear for older adults who have been underrepresented in the research literature. Older adults with rib fractures often have multi-morbidity and frailty which complicate their injuries. Trauma services are evolving, and increasingly geriatricians will be embedded into trauma services to deliver comprehensive geriatric assessment. This review aims to provide an evidence-based overview of the management of rib fractures for the physician treating older patients who have sustained trauma.

Download Full-text

Rib Fracture Location Should be Evaluated When Predicting Morbidity and Mortality in Trauma Patients

The American Surgeon ◽

10.1177/000313481808400950 ◽

2018 ◽

Vol 84 (9) ◽

pp. 1462-1465 ◽

Cited By ~ 2

Author(s):

Krista L. Haines ◽

Tiffany Zens ◽

Charles Warner-Hillard ◽

Edwarda DeSouza ◽

Hee Soo Jung ◽

...

Keyword(s):

Injury Severity Score ◽

Severity Score ◽

Injury Severity ◽

Flail Chest ◽

Rib Fractures ◽

Rib Fracture ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Mortality And Morbidity ◽

Fracture Location

Rib fractures represent up to 55 per cent of thoracic blunt traumatic injuries and lead to significant mortality and morbidity. The aim of this study is to determine whether not only number but also the location of rib fractures can be used to risk stratify patients. This is a retrospective study of all blunt trauma patients who presented with rib fractures from January 1, 2013 to April 1, 2015 and underwent chest CT. Rib fractures were categorized by location. Primary outcome was mortality, secondary outcomes were total hospital length of stay (LOS), intensive care unit LOS, and disposition. Multivariate regressions were performed to determine whether mortality and morbidity was dependent on the number of rib fractures as related to location. Nine hundred and twenty-nine patients were reviewed, 669 fit inclusion criteria, and 35 patients died. Mean Injury Severity Score (18 ± 10), total number of rib fractures (6 ± 5), and age (54 ± 19) significantly correlated with mortality. LOS correlated with the number of rib fractures (P < 0.001). Flail chest of indeterminate location significantly increased mortality (P = 0.002). Controlling for age, gender, and Injury Severity Score and for every lateral rib fracture, patients were 1.13 times (OR; P = 0.001) more likely to die. Posterior rib fractures only effected patient outcome if the patient has three or more posterior ribs broken and the patient was 45 years of age or older (P = 0.044); these patients were 12 times more likely to die. When evaluating blunt force trauma in patients with rib fractures, it is imperative to look at rib fracture location and not only the number of rib fractures sustained to predict outcomes.

Download Full-text

A Comparative Study Between Two Combat Injury Severity Scores

Military Medicine ◽

10.1093/milmed/usab067 ◽

2021 ◽

Author(s):

Rafael García Cañas ◽

Ricardo Navarro Suay ◽

Carlos Rodríguez Moro ◽

Diana M Crego Vita ◽

Javier Arias Díaz ◽

...

Keyword(s):

Injury Severity Score ◽

Severity Score ◽

Injury Severity ◽

Scoring Systems ◽

Combat Injury ◽

New Injury Severity Score ◽

Severity Scores ◽

Trauma Scoring ◽

Combat Casualties ◽

The Military

ABSTRACT Introduction In recent years, specific trauma scoring systems have been developed for military casualties. The objective of this study was to examine the discrepancies in severity scores of combat casualties between the Abbreviated Injury Scale 2005-Military (mAIS) and the Military Combat Injury Scale (MCIS) and a review of the current literature on the application of trauma scoring systems in the military setting. Methods A cross-sectional, descriptive, and retrospective study was conducted between May 1, 2005, and December 31, 2014. The study population consisted of all combat casualties attended in the Spanish Role 2 deployed in Herat (Afghanistan). We used the New Injury Severity Score (NISS) as reference score. Severity of each injury was calculated according to mAIS and MCIS, respectively. The severity of each casualty was calculated according to the NISS based on the mAIS (Military New Injury Severity Score—mNISS) and MCIS (Military Combat Injury Scale-New Injury Severity Score—MCIS-NISS). Casualty severity were grouped by severity levels (mild—scores: 1-8, moderate—scores: 9-15, severe—scores: 16-24, and critical—scores: 25-75). Results Nine hundred and eleven casualties were analyzed. Most were male (96.37%) with a median age of 27 years. Afghan patients comprised 71.13%. Air medevac was the main casualty transportation method (80.13). Explosion (64.76%) and gunshot wound (34.68%) mechanisms predominated. Overall mortality was 3.51%. Median mNISS and MCIS-NISS were similar in nonsurvivors (36 [IQR, 25-49] vs. [IQR, 25-48], respectively) but different in survivors, 9 (IQR, 4-17) vs. 5 (IQR, 2-13), respectively (P < .0001). The mNISS and MCIS-NISS were discordant in 34.35% (n = 313). Among cases with discordant severity scores, the median difference between mNISS and MCIS-NISS was 9 (IQR, 4-16); range, 1 to 57. Conclusion Our study findings suggest that discrepancies in injury severity levels may be observed in one in three of the casualties when using mNISS and MCIS-NISS.

Download Full-text

A Systematic Review Examining the Efficacy of Epidural Analgesia on Mortality in Older Adult Patients with Rib Fractures

10.28971/532019ce132 ◽

2019 ◽

Author(s):

Erin Casimiro

Keyword(s):

Systematic Review ◽

Older Adults ◽

Epidural Analgesia ◽

Older Adult ◽

Patient Population ◽

Effective Means ◽

Pulmonary Complications ◽

Rib Fractures ◽

Definitive Treatment ◽

Increased Risk

Rib fractures are a common consequence of blunt force trauma, producing pain and potentially leading to complications such as pneumonia, atelectasis, respiratory failure, and death. Due to physiological changes related to aging, older adults aged 65 and over are at increased risk for developing such complications. Aggressive treatment of pain has been recognized as paramount in preventing such consequences. While there are multiple modalities to treat pain related to rib fractures, epidural analgesia has frequently been recognized as an effective means of preventing pulmonary complications and decreasing mortality in an opioid sparing technique. However, it remains unclear if this therapy would serve as a definitive treatment in the population of older adults. The purpose of this systematic review was to determine the effect of epidural analgesia on decreasing mortality in the older adult patient population. Literature and pertinent randomized controlled trials were searched for inclusion within this review. Six trials were included within this review utilizing the PRISMA checklist and CASP tool to extract and critically appraise data. Cross study analysis was then utilized to determine overarching themes within the data. This systematic review did not find any statistically significant data to suggest that mortality is decreased in older adults by utilizing epidural analgesia after thoracic trauma. Further research is necessary utilizing prospective data focusing on this particular patient population in order to better determine the effectiveness of this treatment.

Download Full-text

State of Rib Fracture Care: A NTDB Review of Analgesic Management and Surgical Stabilization

The American Surgeon ◽

10.1177/000313481908500523 ◽

2019 ◽

Vol 85 (5) ◽

pp. 474-478 ◽

Cited By ~ 3

Author(s):

Fareed A. Cheema ◽

Edward Chao ◽

Joseph Buchsbaum ◽

Katie Giarra ◽

Afshin Parsikia ◽

...

Keyword(s):

Data Bank ◽

Medication Administration ◽

Rib Fractures ◽

Rib Fracture ◽

Regional Analgesia ◽

Icu Length Of Stay ◽

National Trauma ◽

Fracture Management ◽

National Trauma Data Bank ◽

Recent Trends

Thoracic analgesia plays a key role in management and outcomes of rib fractures and can generally be broken down into oral or parenteral medication administration and regional analgesia. Surgical stabilization of rib fractures (SSRF) may be an underused resource in the management of rib fractures. This study describes recent trends in rib fracture management and outcomes. National Trauma Data Bank datasets from 2008 to 2014 were reviewed. Patients with three or more rib fractures were identified, and the frequencies of epidural analgesia (EA), other regional analgesia, and SSRF were analyzed. Those older than 65 years were more likely to be admitted to the ICU but had shorter ICU length of stay, lower intubation, and need for tracheostomy rates. In addition, those older than 65 years had about 2.5 times higher mortality (6.3% vs 2.6%, P < 0.001). EA was used in only 3 per cent of the population and more commonly in the older than 65 years group (3.7% vs 2.8%, P < 0.001). Regardless of age, SSRF was more commonly performed when compared with the placement of EA (5.8% vs 3%). This difference was even greater in the younger than 65 years group, where 7 per cent underwent SSRF. Utilization of EA remains low nationally. SSRF should be considered not only for chest wall stabilization but also as an analgesic modality in selected patients. A more complete accounting of analgesic care in rib fracture patients is needed to allow a more detailed analysis of analgesia for rib fracture–related pain to elucidate optimal treatment.

Download Full-text

P085: Potential benefits of incentive spirometry following a rib fracture: a propensity-score analysis

CJEM ◽

10.1017/cem.2018.283 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S87-S87

Author(s):

M. Emond ◽

A. Laguë ◽

B. Batomen Kuimi ◽

V. Boucher ◽

C. Guimont ◽

...

Keyword(s):

Propensity Score ◽

Propensity Score Analysis ◽

Pulmonary Complications ◽

Rib Fractures ◽

Rib Fracture ◽

Thoracic Injury ◽

Main Complaint ◽

Score Analysis ◽

Discharged Patients ◽

Incentive Spirometry

Introduction: Incentive spirometry (IS) is commonly used in post-operative patients for respiratory recovery. Literature suggest that it can possibly improve lung function and reduce post-operative pulmonary complication. There is no recommendation about the use of IS in the emergency department (ED). However, rib fractures, a common complaint, increase the risk of pulmonary complications. There is heterogeneous ED practice for the management of rib fractures. The objective of this study is to assess the benefits of IS to reduce potential delayed complications in ED discharged patients with confirmed rib fracture. Methods: This is a prospective observational planned sub-study in 4 canadians ED between November 2006 and May 2012. Non-admitted patients over 16 y.o. with a main complaint of minor thoracic injury and at least one suspected/confirmed rib fracture on radiographs were included. Discharge recommendations of IS use was left to attending physician. IS training was done by ED nurses. Main outcomes were pneumonia, atelectasis and hemothorax within 14 days. Analyses were made with propensity score matching. Results: 450 patients with at least one rib fracture were included. Of these, 182 (40%) received IS with a mean age of 57.0 y.o. Patients with IS seem to have worse condition. 61 (33.5%) had 3 fractures comparatively to 56 (20.9) for patient without IS. Although, the groups were similar for mean age, sex and mechanism of injury. There were in total 76 cases of delayed hemothorax (16.9%), 69 cases of atelectasis (15.3%) and five cases of pneumonia (1.1%). The use of IS was not protector for delayed hemothorax (RR= 0.80, 95% CI [0.45 1.36]) and nor for atelectasis or pneumonia (RR=0.74, 95% CI [0.45 1.36]) Conclusion: Our results suggest that unsupervised and broad incentive spirometry use does not seem to add a protective effect against the development of delayed pulmonary complications after a rib fracture. Further study should be made to assess the usefulness of IS in specific injured population in the ED.

Download Full-text

Incidence and Outcomes of Critical Illness-Related Corticosteroid Insufficiency in Trauma Patients

The American Surgeon ◽

10.1177/000313481107700517 ◽

2011 ◽

Vol 77 (5) ◽

pp. 579-585

Author(s):

Mark L. Walker ◽

Phillip S. Owen ◽

Candace Sampson ◽

Janene Marshall ◽

Teresa Pounds ◽

...

Keyword(s):

Critical Illness ◽

Injury Severity ◽

Strong Predictor ◽

Trauma Patients ◽

Mortality And Morbidity ◽

Clinical Criteria ◽

Severity Scores ◽

Prolonged Duration ◽

Injured Patients ◽

Corticosteroid Insufficiency

The spectrum of critical illness-related corticosteroid insufficiency (CIRCI) in trauma is not fully defined. This study describes our trauma experience with hydrocortisone-treated patients experiencing CIRCI. We conducted a 5-year retrospective analysis from a Level II trauma center using biochemical and clinical criteria for adrenal insufficiency. Seventy patients met the inclusion criteria for CIRCI. There was a 34 per cent mortality rate despite therapy. Nonsurvivors were older with larger admission base deficits and experienced higher rates of sepsis, bacteremia, and pneumonia. Nonsurvivors had prolonged vent days (mean 53 ± 64 days) when compared with survivors (mean 30 ± 22 days; P = 0.029). Renal replacement therapy was a strong predictor of mortality. Spinal cord-injured patients had high Injury Severity Scores (mean 34 ± 18), elevated baseline Cortisol levels (mean 56 ± 84 vs 18 ± 14; P = 0.004), and required prolonged duration of steroid therapy (30 ± 52 vs 15 ± 15 days; P = 0.080) when compared with the nonspinal cord-injured group. Our data suggest that CIRCI in trauma is associated with significant mortality and morbidity even when patients are treated appropriately.

Download Full-text

Do Lidocaine Patches Reduce Opioid Use in Acute Rib Fractures?

The American Surgeon ◽

10.1177/0003134820945224 ◽

2020 ◽

Vol 86 (9) ◽

pp. 1153-1158

Author(s):

Matthew Johnson ◽

Lauren Strait ◽

Ashar Ata ◽

Ashley Bartscherer ◽

Claire Miller ◽

...

Keyword(s):

Length Of Hospital Stay ◽

Hospital Length ◽

Pulmonary Complications ◽

Rib Fractures ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Opioid Use ◽

Trauma Service ◽

Fracture Management ◽

Multimodal Care

Background Pain control is an important aspect of rib fracture management. With a rise in multimodal care approaches, we hypothesized that transdermal lidocaine patches reduce opioid utilization in hospitalized patients with acute rib fractures not requiring continuous opioid infusion. Methods We performed a retrospective analysis of adult trauma patients with acute rib fractures admitted to the Trauma Service from January 2011 to October 2018. We compared patients who received transdermal lidocaine patches to those who did not and evaluated cumulative opioid consumption, expressed in morphine milligram equivalents (MMEs). Secondary outcomes included the rate of pulmonary complications and length of hospital stay. Results Of the 21 190 trauma admissions, 3927 (18.5%) had rib fractures. Overall, 1555 patients who received continuous opioid infusion were excluded. Of the remaining 2372 patients, 725 (30.6%) patients received lidocaine patches. The mean total MME of patients who received lidocaine patches was 55.7 MME (30.7 MME on multivariate analysis) and was lower than that of patients who did not receive lidocaine patches ( P ≤ .01). There was no difference in hospital length of stay (no lidocaine patches vs received lidocaine patches: 6.2 days vs 6.5 days, P = .34) or pulmonary complications (1.7% vs 2.8%, P = .08). Discussion In admitted trauma patients with acute rib fractures not requiring continuous intravenous opiates, lidocaine patch use was associated with a significant decrease in opiate utilization during the patients’ hospital course.

Download Full-text

Chest trauma in the older people: epidemiological profile and treatment outcome

International Surgery Journal ◽

10.18203/2349-2902.isj20183187 ◽

2018 ◽

Vol 5 (8) ◽

pp. 2697

Author(s):

Kelechi E. Okonta ◽

Emmanuel O. Ocheli

Keyword(s):

Older Persons ◽

Chest Trauma ◽

Injury Severity ◽

Rib Fracture ◽

Chest Injury ◽

Thoracic Injury ◽

Associated Injury ◽

Severity Scores ◽

Epidemiological Profile ◽

Neurological Injuries

Background: There has not been any documented account of chest trauma among the older persons in Nigeria. The aim is to determine the epidemiological profile of chest injury in the old population.Methods: A prospective study of all the patients with chest trauma in two Nigeria tertiary hospitals for 4 years period. The bio-data, cause and type of chest injury, time between injury and presentation in the hospital, number of rib fractures, associated injury, injury severity score (ISS), treatment and outcome were analyzed using range and mean.Results: A total of 38(15.8%) older persons of 241 patients with chest trauma were analysed. Twenty-two (57.9%) patients were male with most of the patients being farmers and unskilled workers. Twenty-four (63.2%) patients sustained chest injury from motor vehicular crash while 10(26.3%) patients were from falls,2(5.3%) patients from gunshot injury and 2(5.3%) patients from other causes. The time between injury and presentation to the hospital ranged from 30-minutes to 5-days. Twenty-seven patients (71.1%) had rib fracture. The associated injuries were limb bone injuries in 10 (26.3%) patients, blunt abdominal injuries in 2(5.3%) patients and neurological injuries in 4 (10.6%) patients. The treatment in 35 (92.1%) patients was at least by chest tube insertion. The 30-day hospital mortality was 3(7.9%) from patients with injury severity scores of 32, 41 and 48 respectively.Conclusions: Traumatic chest injury in the older persons is still not common. Trauma to the limb bones was the commonest associated injury, and rib fracture was the commonest thoracic injury encountered. However, expeditious management led to reduced mortality recorded in this study.

Download Full-text

Ketorolac Use for Pain Management in Trauma Patients With Rib Fractures Does not Increase of Acute Kidney Injury or Incidence of Bleeding

The American Surgeon ◽

10.1177/0003134820954835 ◽

2020 ◽

pp. 000313482095483

Author(s):

Julia Torabi ◽

Jody M. Kaban ◽

Erin Lewis ◽

Dana Laikhram ◽

Rachel Simon ◽

...

Keyword(s):

Acute Kidney Injury ◽

Pain Management ◽

Injury Severity ◽

Kidney Injury ◽

Rib Fractures ◽

Rib Fracture ◽

Trauma Patients ◽

Bleeding Events ◽

Transfusion Requirements ◽

Intravenous Ketorolac

Introduction Ketorolac is useful in acute pain management to avoid opiate-related complications; however, some surgeons fear associated acute kidney injury (AKI) and bleeding despite a paucity of literature on ketorolac use in trauma patients. We hypothesized that our institution's use of intravenous ketorolac for rib fracture pain management did not increase the incidence of bleeding or AKI. Methods Rib fracture patients aged 15 years and above admitted between January 2016-June 2018 were identified in our trauma registry along with frequency of bleeding events. AKI was defined as ≥ 1.5x increase in serum creatinine from baseline measured on the second day of admission (after 24 hours of resuscitation) or an increase of ≥ .3 mg/dL over a 48-hour period. Patients receiving ketorolac were compared to patients with no ketorolac use. Results Two cohorts of 199 control and 205 ketorolac patients were found to be similar in age, gender, admission systolic blood pressure (SBP), injury severity score, intravenous radiocontrast received, and transfusion requirements. Analysis revealed no difference in frequency of AKI using both definitions (8% vs. 7.3%, P = .79) and (19.6% vs. 15.1%, P = .24), respectively, or bleeding events (2.5% vs. 0%, P = .03). Logistic regression demonstrated that ketorolac use was not an independent predictor for AKI but age and admission SBP < 90 were. Conclusion Use of ketorolac in this cohort of trauma patients with rib fractures did not increase the incidence of AKI or bleeding events.

Download Full-text

Testing the clinical validity of the Bemelman Rib Fracture Management Guideline

Interactive CardioVascular and Thoracic Surgery ◽

10.1093/icvts/ivz317 ◽

2020 ◽

Vol 30 (4) ◽

pp. 597-599

Author(s):

Jessica R Dorman ◽

Peter T M Clarke ◽

Rosalind B Simpson ◽

John G Edwards

Keyword(s):

Rib Fractures ◽

Rib Fracture ◽

Management Guideline ◽

Predictive Values ◽

Multiple Rib Fractures ◽

Fracture Management ◽

Computed Tomography Scans ◽

Surgical Fixation ◽

A Prospective Study ◽

Selection Algorithms

Abstract Whilst surgical stabilization of rib fractures (SSRF) results in better outcomes, selection algorithms are lacking. We aimed to validate the Rib Fracture Management Guideline proposed by Bemelman. From a cohort of 792 patients with multiple rib fractures, 2 sequential cohorts were selected: 48 patients who underwent SSRF and 48 patients who managed conservatively. Admission computed tomography scans and records were reviewed by an investigator blinded to the SSRF outcome. Adherence to the Bemelman guideline, revised to take account of consensus rib fracture definitions, was tested. Fifty-seven patients had multiple rib fractures only, and 39 patients also had a flail segment. Thirty-nine patients with flail segment underwent SSRF, and 18 patients were managed conservatively. Of the patients that the guideline predicted should have received surgery, 87% did. Of those that it predicted should not receive SSRF, 98% did not. The guideline displayed a sensitivity (95% confidence interval) and specificity for predicting the fixation of 0.98 (0.89–0.9995) and 0.83 (0.70–0.93), respectively. The positive and negative predictive values for surgical fixation were 0.87 (0.76–0.92) and 0.98 (0.85–0.99), respectively. The Bemelman guideline was thus a good predictor of SSRF in retrospective cohort but should be used in conjunction with clinical judgement. Further validation is indicated in a prospective study.

Download Full-text