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Mukherjee K, Schubl SD, Tominaga G, Cantrell S, Kim B, Haines KL, Kaups KL, Barraco R, Staudenmayer K, Knowlton LM, Shiroff AM, Bauman ZM, Brooks SE, Kaafarani H, Crandall M, Nirula R, Agarwal SK, Como JJ, Haut ER, Kasotakis G. Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society. J Trauma Acute Care Surg 2023; 94:398-407. [PMID: 36730672 DOI: 10.1097/ta.0000000000003830] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia. METHODS Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used. RESULTS Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality. CONCLUSION We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia. LEVEL OF EVIDENCE Systematic Review/Meta-analysis; Level IV.
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Affiliation(s)
- Kaushik Mukherjee
- From the Division of Acute Care Surgery, Loma Linda University Medical Center (K.M.), Loma Linda; University of California Irvine Medical Center (S.D.S.), Irvine; Scripps Memorial La Jolla (G.T.), San Diego, California; Division of Trauma and Critical Care Surgery, Department of Surgery (S.C., K.L.H., S.K.A., G.K.), Duke University Medical Center, Durham, North Carolina; The Mayo Clinic (B.K.), Rochester, Minnesota; University of California San Francisco-Fresno (K.L.K.), Fresno, California; Lehigh Valley Health Network (R.B.), Allentown, Pennsylvania; Stanford University Medical Center (K.S., L.M.K.), Palo Alto, California; University of Pennsylvania Medical Center (A.M.S.), Philadelphia, Pennsylvania; University of Nebraska Medical Center (Z.M.B.), Omaha, Nevada; Texas Tech University Health Sciences Center (S.E.B.), Lubbock, Texas; Massachusetts General Hospital (H.K.), Boston, Massachusetts; University of Florida College of Medicine (M.C.), Jacksonville, Florida; University of Utah Medical Center (R.N.), Salt Lake City, Utah; MetroHealth Cleveland Medical Center (J.J.C.), Cleveland, Ohio; Johns Hopkins Medical Center (E.R.H.), Baltimore, Maryland
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Dogrul BN, Kiliccalan I, Asci ES, Peker SC. Blunt trauma related chest wall and pulmonary injuries: An overview. Chin J Traumatol 2020; 23:125-138. [PMID: 32417043 PMCID: PMC7296362 DOI: 10.1016/j.cjtee.2020.04.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/15/2020] [Accepted: 04/08/2020] [Indexed: 02/04/2023] Open
Abstract
Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.
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Tulay CM, Yaldiz S, Bilge A. Do we really know the duration of pain after rib fracture? KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2018; 15:147-150. [PMID: 30310391 PMCID: PMC6180016 DOI: 10.5114/kitp.2018.78437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/03/2018] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The duration of pain after rib fracture is the question physicians are most frequently asked. The duration of pain following a traumatic rib fracture without any comorbidity is not widely published. AIM We report our experience to investigate the duration of pain following isolated traumatic rib fractures without any traumatic comorbidity. MATERIAL AND METHODS We examined 182 patients with isolated rib fracture without any trauma to other body parts. The numeric rating scale (NRS) for pain was used to rate the level of pain. The NRS pain scores were evaluated in the emergency department at presentation, on the 15th day, and at the 3rd and 6th months of trauma. The Mann-Whitney U test was performed for the statistical analysis. RESULTS The pain level of young patients on the 15th day and at the third month and sixth month was lower than that in the old group, and the difference was statistically significant. While patients with two rib fractures had a higher pain level in the emergency room than those with one rib fracture, there was no statistically significant difference at other time points. In patients with anterior fractures, the pain level was significantly lower than in the lateral and posterior regions, whereas in the lateral fractures, the pain score was significantly higher than others at all time points except at the 6th month. The pain score of displaced fractures was significantly higher than that of non-displaced ones at all time points except the 6-month follow-up. CONCLUSIONS Rib fractures cause significant pain and need appropriate medication. The time of the 6th month could be an important milestone.
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Affiliation(s)
- Cumhur Murat Tulay
- Thoracic Surgery Department, School of Medicine, Manisa Celal Bayar University, Manisa, Turkey
| | - Sadik Yaldiz
- Thoracic Surgery Department, School of Medicine, Manisa Celal Bayar University, Manisa, Turkey
| | - Adnan Bilge
- Emergency Department, School of Medicine, Manisa Celal Bayar University, Manisa, Turkey
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Development of a blunt chest injury care bundle: An integrative review. Injury 2018; 49:1008-1023. [PMID: 29655592 DOI: 10.1016/j.injury.2018.03.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Blunt chest injuries (BCI) are associated with high rates of morbidity and mortality. There are many interventions for BCI which may be able to be combined as a care bundle for improved and more consistent outcomes. OBJECTIVE To review and integrate the BCI management interventions to inform the development of a BCI care bundle. METHODS A structured search of the literature was conducted to identify studies evaluating interventions for patients with BCI. Databases MEDLINE, CINAHL, PubMed and Scopus were searched from 1990-April 2017. A two-step data extraction process was conducted using pre-defined data fields, including research quality indicators. Each study was appraised using a quality assessment tool, scored for level of evidence, then data collated into categories. Interventions were also assessed using the APEASE criteria then integrated to develop a BCI care bundle. RESULTS Eighty-one articles were included in the final analysis. Interventions that improved BCI outcomes were grouped into three categories; respiratory intervention, analgesia and surgical intervention. Respiratory interventions included continuous positive airway pressure and high flow nasal oxygen. Analgesia interventions included regular multi-modal analgesia and paravertebral or epidural analgesia. Surgical fixation was supported for use in moderate to severe rib fractures/BCI. Interventions supported by evidence and that met APEASE criteria were combined into a BCI care bundle with four components: respiratory adjuncts, analgesia, complication prevention, and surgical fixation. CONCLUSIONS The key components of a BCI care bundle are respiratory support, analgesia, complication prevention including chest physiotherapy and surgical fixation.
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Peek J, Smeeing DPJ, Hietbrink F, Houwert RM, Marsman M, de Jong MB. Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2018; 45:597-622. [PMID: 29411048 PMCID: PMC6689037 DOI: 10.1007/s00068-018-0918-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 01/31/2018] [Indexed: 02/04/2023]
Abstract
Purpose Many studies report on outcomes of analgesic therapy for (suspected) traumatic rib fractures. However, the literature is inconclusive and diverse regarding the management of pain and its effect on pain relief and associated complications. This systematic review and meta-analysis summarizes and compares reduction of pain for the different treatment modalities and as secondary outcome mortality during hospitalization, length of mechanical ventilation, length of hospital stay, length of intensive care unit stay (ICU) and complications such as respiratory, cardiovascular, and/or analgesia-related complications, for four different types of analgesic therapy: epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks. Methods PubMed, EMBASE and CENTRAL databases were searched to identify comparative studies investigating epidural, intravenous, paravertebral and intercostal interventions for traumatic rib fractures, without restriction for study type. The search strategy included keywords and MeSH or Emtree terms relating blunt chest trauma (including rib fractures), analgesic interventions, pain management and complications. Results A total of 19 papers met our inclusion criteria and were finally included in this systematic review. Significant differences were found in favor of epidural analgesia for the reduction of pain. No significant differences were observed between epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks, for the secondary outcomes. Conclusions Results of this study show that epidural analgesia provides better pain relief than the other modalities. No differences were observed for secondary endpoints like length of ICU stay, length of mechanical ventilation or pulmonary complications. However, the quality of the available evidence is low, and therefore, preclude strong recommendations.
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Affiliation(s)
- Jesse Peek
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Diederik P J Smeeing
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Utrecht Traumacenter, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Utrecht Traumacenter, Utrecht, The Netherlands
| | - Marije Marsman
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mirjam B de Jong
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Park HB, Hyun SY, Kim JJ, Jang YS. Prognosis of Pulmonary Function in Patients with Multiple Rib Fractures. JOURNAL OF TRAUMA AND INJURY 2017. [DOI: 10.20408/jti.2017.30.4.179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Hee Beom Park
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Sung Youl Hyun
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Jin Joo Kim
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yeon Sik Jang
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg 2017; 81:936-951. [PMID: 27533913 DOI: 10.1097/ta.0000000000001209] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented. METHODS Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay. RESULTS Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel. CONCLUSION We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.
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Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017; 48:307-321. [PMID: 27912931 DOI: 10.1016/j.injury.2016.11.026] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/05/2016] [Accepted: 11/21/2016] [Indexed: 02/02/2023]
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Akkuş M, Utkusavaş A, Hanözü M, Kaya M, Bakir I. Stabilization of Flail Chest and Fractured Sternum by Minimally Invasive Repair of Pectus Excavatum. Thorac Cardiovasc Surg Rep 2015; 4:11-3. [PMID: 26693119 PMCID: PMC4670315 DOI: 10.1055/s-0035-1563399] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 06/26/2015] [Indexed: 12/02/2022] Open
Abstract
We report a 55-year-old male patient with a massive flail chest that required chest stabilization by minimally invasive repair of pectus excavatum (MIRPE) employing a Nuss bar. Surgical stabilization of severe flail chest and fractured sternum with Nuss bar by MIRPE is a safe and useful treatment modality in properly selected patients.
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Affiliation(s)
- Murat Akkuş
- Department of Thoracic Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ayfer Utkusavaş
- Department of Pulmonology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Hanözü
- Department of Thoracic Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Kaya
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ihsan Bakir
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Kim WS, Kim JS. Delayed Diaphragmatic Injury with Massive Hemothorax Due to Lower Rib Fracture. JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.2.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Woo-Shik Kim
- Department of Thoracic and Cardiovascular Surgery, National Medical Center, Seoul, Korea
| | - Joong-Suck Kim
- Department of Trauma Surgery, National Medical Center, Seoul, Korea
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Park S. Clinical Analysis for the Correlation of Intra-abdominal Organ Injury in the Patients with Rib Fracture. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:246-50. [PMID: 22880170 PMCID: PMC3413830 DOI: 10.5090/kjtcs.2012.45.4.246] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Revised: 03/19/2012] [Accepted: 06/02/2012] [Indexed: 11/16/2022]
Abstract
Background Although it is rare for the fracture itself to become a life threatening injury in patients suffering from rib fracture, the lives of these patients are occasionally threatened by other associated injuries. Especially, early discovery of patients with rib fracture and intra-abdominal organ injury is extremely important to the prognosis. This study analyzed the link between rib fracture and intra-abdominal injury to achieve improved treatment. Materials and Methods Among trauma patients that had visited the hospital emergency room from January 2007 to December 2009, a retrospective study was conducted on 453 patients suffering from rib fracture due to blunt trauma. Rib fracture was classified according to location (left, right, and bilateral), and according to level (upper rib fracture [1-2nd rib], middle rib fracture [3-8th rib], and lower rib fracture [9-12th rib]). The researched data was statistically compared and analyzed to investigate the correlation between the location, level, and number of rib fracture and intra-abdominal organ injury. Results Motor vehicle injury was found to be the most common mechanism of injury with 208 cases (46%). Associated injuries accompanied with rib fracture were generated in 276 cases (61%). Intra-abdominal organ injury was discovered in 97 cases (21%). Liver injury was the most common intra-abdominal injury associated with rib fracture with 39 cases (40%), followed by spleen injury, with 23 cases (23%). Intra-abdominal injury according to level of rib fracture was presented as upper rib fracture in 11 cases (11%), middle rib fracture in 31 cases (32%), and lower rib fracture in 55 cases (57%), thus verifying that intra-abdominal injuries were commonly accompanied in lower rib fractures (p=0.03). In particular, significant increase of intra-abdominal injury was presented in fractures below the 8th rib (p=0.03). The number of intra-abdominal injuries requiring emergency operations was significantly higher in patients with more than 6 rib fractures (p=0.04). Conclusion Intra-abdominal organ injury is more common in patients with lower rib fracture, especially fractures below the 8th rib. Intra-abdominal organ injuries generated in multiple rib fracture patients with more than 6 fractures significantly higher severity. These cases must be thoroughly inspected and carefully observed as there is possibility of emergency operation.
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Affiliation(s)
- Seongsik Park
- Department of Thoracic and Cardiovascular Surgery, Dankook University College of Medicine, Korea
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Aukema TS, Beenen LFM, Hietbrink F, Leenen LPH. Initial assessment of chest X-ray in thoracic trauma patients: Awareness of specific injuries. World J Radiol 2012; 4:48-52. [PMID: 22423318 PMCID: PMC3304093 DOI: 10.4329/wjr.v4.i2.48] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Revised: 09/07/2011] [Accepted: 09/14/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the reported injuries on initial assessment of the chest X-ray (CXR) in thoracic trauma patients to a second read performed by a dedicated trauma radiologist.
METHODS: By retrospective analysis of a prospective database, 712 patients with an injury to the chest admitted to the University Medical Center Utrecht were studied. All patients with a CXR were included in the study. Every CXR was re-evaluated by a trauma radiologist, who was blinded for the initial results. The findings of the trauma radiologist regarding rib fractures, pneumothoraces, hemothoraces and lung contusions were compared with the initial reports from the trauma team, derived from the original patient files.
RESULTS: A total of 516 patients with both thorax trauma and an initial CXR were included in the study. After re-evaluation of the initial CXR significantly more lung contusions (53.3% vs 34.1%, P < 0.001), hemothoraces (17.8% vs 11.0%, P < 0.001) and pneumothoraces (34.4% vs 26.4%, P < 0.001) were detected. During initial assessment significantly more rib fractures were reported (69.8% vs 62.3%, P < 0.001).
CONCLUSION: During the initial assessment of a CXR from trauma patients in the emergency department, a significant number of treatment-dictating injuries are missed. More awareness for these specific injuries is needed.
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Treatment of Traumatic Flail Chest With Muscular Sparing Open Reduction and Internal Fixation: Description of a Surgical Technique. ACTA ACUST UNITED AC 2011; 71:494-501. [DOI: 10.1097/ta.0b013e3182255d30] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture. Int J Surg 2011; 9:478-81. [PMID: 21763475 DOI: 10.1016/j.ijsu.2011.06.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Revised: 05/24/2011] [Accepted: 06/01/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the intensity of pain and duration of return to normal activity in patients with rib fractures treated with surgical stabilization with plating versus conventional treatment modalities. PATIENTS AND METHODS This study was conducted over a 12 month period. Patients with rib fractures were assessed by numerical pain scale. Patients having pain scale less than 5 were excluded from study. Patients having pain scale of 5 or more than 5 were treated with conventional treatment for next 10 days. On 11th day patients were again assessed by numerical pain scale and patients having score less than 5 were excluded from study. Patients having pain scale of 5, 6, and 7 were treated with conventional treatment and patients having pain scale of 8, 9, and 10 were selected for operative management. Operative and control group were compared on basis of intensity of pain and duration of return to normal activity. Follow up was done on 5, 15, and 30 post operative day. RESULTS There was less pain in operative group as compared to control group. Mean rib fracture pain in operative group was 9.15, 2.31, 1.12 as compared to 6.25, 5.96, 4.50 in control group on 5, 15 and 30 post operative days. Also there was early return to normal activity in operative group. CONCLUSION Surgical stabilization of rib fracture, an underutilized intervention is better than conventional conservative management in terms of both, decrease in intensity of pain and early return to normal activity.
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Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am 2011; 93:97-110. [PMID: 21209274 DOI: 10.2106/jbjs.i.00696] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Most injuries to the chest wall with residual deformity do not result in long-term respiratory dysfunction unless they are associated with pulmonary contusion. Indications for operative fixation include flail chest, reduction of pain and disability, a chest wall deformity or defect, symptomatic nonunion, thoracotomy for other indications, and open fractures. Operative indications for chest wall injuries are rare.
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Affiliation(s)
- Paul M Lafferty
- University of Minnesota-Regions Hospital, St. Paul, Minnesota 55101, USA
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Kim HY, Kim MY. Management of Patients with Rib Fractures: Analysis of the Risk Factors Affecting the Outcome. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.3.285] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Han Yong Kim
- Department of Thoracic and Cardiovascular Surgery, Masan Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Myoung Young Kim
- Department of Thoracic and Cardiovascular Surgery, Masan Samsung Hospital, Sungkyunkwan University School of Medicine
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Abstract
Rib fractures (RF) are noted in 4 to 12 per cent of trauma admissions. To define RF risks at a Level 1 trauma center, investigators conducted a 10-year (1995-2004) retrospective analysis of all trauma patients. Blunt chest trauma was seen in 13 per cent (1,475/11,533) of patients and RF in 808 patients (55% blunt chest trauma, 7% blunt trauma). RF were observed in 26 per cent of children (< 18 years), 56 per cent of adults (18-64 years), and 65 per cent of elderly patients (> or = 65 years). RF were caused by motorcycle crashes (16%, 57/347), motor vehicle crashes (12%, 411/3493), pedestrian-auto collisions (8%, 31/404), and falls (5%, 227/5018). Mortality was 12 per cent (97/808; children 17%, 8/46; adults 9%, 46/522; elderly 18%, 43/240) and was linearly associated with a higher number of RF (5% 1-2 RF, 15% 3-5 RF, 34% > or = 6 RF). Elderly patients had the highest mortality in each RF category. Patients with an injury severity score > or = 15 had 20 per cent mortality versus 2.7 per cent with ISS < 15 (P < 0.0001). Increasing age and number of RF were inversely related to the percentage of patients discharged home. ISS, age, number of RF, and injury mechanism determine patients' course and outcome. Patients with associated injuries, extremes of age, and > or = 3 RF should be admitted for close observation.
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Affiliation(s)
- Om P Sharma
- Department of Trauma Services, The Toledo Hospital and Toledo Children's Hospital, Toledo, Ohio, USA
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Bakhos C, O'Connor J, Kyriakides T, Abou-Nukta F, Bonadies J. Vital Capacity as a Predictor of Outcome in Elderly Patients with Rib Fractures. ACTA ACUST UNITED AC 2006; 61:131-4. [PMID: 16832260 DOI: 10.1097/01.ta.0000223463.88422.6a] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study tests the relationships between early bedside vital capacity (VC) measurement and morbidity, mortality, and resource consumption in geriatric blunt chest trauma patients with rib fractures. METHODS This was a retrospective study examining all patients > or = 65 years old with rib fractures who had a VC measured within 48 hours of their emergency department evaluation. Outcome variables included pulmonary complications, death from pulmonary complications, hospital length of stay (LOS), intensive care unit length of stay (ICU LOS), and discharge disposition. RESULTS Thirty-eight patients met the study criteria. The mean age was 80.2 (+/-7.4) years, the mean number of rib fractures was 3.6 (+/-1.6), and the mean ISS was 6.9 (+/-4.7). VC and the percentage of the predicted vital capacity (pVC) were both inversely correlated with LOS (p = 0.0076 and p = 0.0172, respectively). Linear regression analysis suggested that patients with a VC < 1.4 L or < 55% of their pVC had a LOS > 3 days. Mean VC was 36% higher in patients who were discharged home versus those discharged to an extended care facility (ECF; p = 0.025). There was a trend toward significance when comparing VC to ICU LOS (p = 0.079), but none in predicting pulmonary complications (p = 0.3299). No correlations between VC and mortality can be drawn given the single death in the cohort. CONCLUSIONS Bedside VC is a simple measurement which could predict LOS in elderly patients with rib fractures and may identify those patients requiring ECF upon discharge. Further prospective study may highlight the utility of emergency room VC in determining the disposition of these patients.
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Affiliation(s)
- Charles Bakhos
- Department of Surgery, Hospital of Saint Raphael, New Haven, Connecticut 06511, USA.
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Abstract
Trauma is a major cause of mortality throughout the world. In recent years, major advances have been made in the management of trauma, the end result of which has been reduced mortality and enhanced function. One of these areas is pain control. Improved pain management has not only led to increased comfort in trauma patients, but has also been shown to reduce morbidity and improve long-term outcomes. This review focuses on the treatment of pain in the setting of acute injury and on pain management in trauma patients who go on to develop chronic pain. Emphasis is placed on pharmacologic interventions, invasive and noninvasive pain management techniques, analgesia in challenging patients, and pain control in commonly encountered trauma conditions.
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Affiliation(s)
- Steven P Cohen
- Pain Management Center, Department of Anesthesiology, New York University School of Medicine, New York, NY, USA
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Kerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain and disability: can we do better? THE JOURNAL OF TRAUMA 2003; 54:1058-63; discussion 1063-4. [PMID: 12813323 DOI: 10.1097/01.ta.0000060262.76267.ef] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the magnitude and duration of pain and disability in patients with rib fractures treated using current standard therapy. This was a prospective case series. METHODS Injured patients with a chest radiographic diagnosis of one or more rib fractures between June 1, 2001, and October 31, 2001, were asked to participate. Pain levels were assessed at days 1, 5, 30, and 120 after injury using a visual pain scale (0-10). Disability at 30 days was assessed using the SF-36 Health Status Survey, and the total number of days lost from work/usual activity was recorded at day 120. The setting was a university-based Level I trauma center. RESULTS Forty patients with a mean of 2.7 +/- 1.6 rib fractures were enrolled. Twenty-three patients had isolated rib fractures and 17 patients had associated extrathoracic injuries. Mean rib fracture pain was 3.5 +/- 2.1 at 30 days and 1.0 +/- 1.4 at 120 days. For patients with associated extrathoracic injuries, rib pain was equivalent to pain in the rest of the body at all intervals. When compared with the chronically ill reference population of the RAND Medical Outcomes Study, our patients as a group were more disabled at 30 days (p < 0.001) in all categories except emotional stability, where they showed equivalent disability, and in their perception of general health, where they were significantly less disabled (p < 0.001). The total mean days lost from work/usual activity was 70 +/- 41. Patients with isolated rib fractures went back to work/usual activity at a mean of 51 +/- 39 days compared with 91 +/- 33 days in patients with associated extrathoracic injuries (p < 0.01). CONCLUSION Rib fractures are a significant cause of pain and disability in patients with isolated thoracic injury and in patients with associated extrathoracic injuries. Developing new therapies to accelerate pain relief and healing would substantially improve the outcome of patients with rib fractures.
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Karmakar MK, Ho AMH. Acute pain management of patients with multiple fractured ribs. THE JOURNAL OF TRAUMA 2003; 54:615-25. [PMID: 12634549 DOI: 10.1097/01.ta.0000053197.40145.62] [Citation(s) in RCA: 208] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Multiple rib fracture causes severe pain that can seriously compromise respiratory mechanics and exacerbate underlying lung injury and pre-existing respiratory disease, predisposing to respiratory failure. The cornerstone of management is early institution of effective pain relief, the subject of this review. METHODS A MEDLINE search was conducted for the years 1966 through and up to December 2002 for human studies written in English using the keywords "rib fractures", "analgesia", "blunt chest trauma", "thoracic injury", and "nerve block". The reference list of key articles was also searched for relevant articles. The various analgesic techniques used in patients with multiple fractured ribs were summarized. RESULTS Analgesia could be provided using systemic opioids, transcutaneous electrical nerve stimulation or non steroidal anti-inflammatory drugs. Alternatively, regional analgesic techniques such as intercostal nerve block, epidural analgesia, intrathecal opioids, interpleural analgesia and thoracic paravertebral block have been used effectively. Although invasive, in general, regional blocks tend to be more effective than systemic opioids, and produce less systemic side effects. CONCLUSION Based on current evidence it is difficult to recommend a single method that can be safely and effectively used for analgesia in all circumstances in patients with multiple fractured ribs. By understanding the strengths and weaknesses of each analgesic technique, the clinician can weigh the risks and benefits and individualize pain management based on the clinical setting and the extent of trauma.
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Affiliation(s)
- Manoj K Karmakar
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR, People's Republic of China.
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Oncel M, Sencan S, Yildiz H, Kurt N. Transcutaneous electrical nerve stimulation for pain management in patients with uncomplicated minor rib fractures. Eur J Cardiothorac Surg 2002; 22:13-7. [PMID: 12103366 DOI: 10.1016/s1010-7940(02)00206-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Few non-surgical conditions are more painful than rib fractures. There are a few methods for pain relief in patients with minor rib fractures. METHODS We used a non-steroidal anti-inflammatory drug (NSAID, Naproxen sodium) and transcutaneous electrical nerve stimulator (TENS) to control pain of the patients with uncomplicated minor rib fractures. One hundred consecutive patients admitted to Kartal Education and Research Hospital Emergency Service, were randomized into four groups. The patients were assigned to one of the following pain treatments: NSAID, TENS, NSAID plus inactive TENS or placebo. The patients used NSAIDs and placebo four times a day and TENS twice a day for 3 days. All patients were asked to assess their pain level with a scoring system on days 0, 1 and 3. RESULTS The most effective treatment was TENS on days 1 and 3 (P<0.05). Although NSAID and NSAID plus inactive TENS controlled pain better than placebo on day 1 (P<0.05), this superiority did not continue to day 3 (P>0.05). There was no difference between NSAID and NSAID plus inactive TENS in controlling pain on either days 1 or 3. CONCLUSION We conclude that TENS was more effective than NSAID or placebo in patients with uncomplicated minor rib fractures, because of its prominent and admirable efficacy in reduction of pain.
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Affiliation(s)
- Mustafa Oncel
- Kartal Education and Research Hospital, Department of General Surgery, Cevizli-Istanbul, Turkey.
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Bansidhar BJ, Lagares-Garcia JA, Miller S. Clinical Rib Fractures: Are Follow-Up Chest X-Rays A Waste of Resources? Am Surg 2002. [DOI: 10.1177/000313480206800511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Rib fractures (RFs) are estimated to be present in 10 per cent of all traumatic injuries. However, up to 50 per cent of all fractures go undetected on the screening chest X-ray (CXR). The purpose of this study was to identify the incidence of clinical (CRFs) and objective rib fractures (ORFs) as well as to examine the utility of the routine follow-up CXR with regard to patient recovery and healthcare cost. We identified patients sustaining RF in addition to other traumatic injuries with an Injury Severity Score (ISS) ≤15 and RF as the primary pathology. Five hundred fifty-two patients sustained blunt thoracic trauma with resultant RF. Two hundred nine patients had RFs and an ISS ≤15. The average ISS was 8. Follow-up films illustrated that 93 per cent of CRFs had resolution of any pathology, 4 per cent had persistent X-ray findings, and 4 per cent were lost to follow-up. Ultimately 93 per cent of patients with CRF were able to resume daily activities without disability and 3 per cent incurred lifestyle changes at home or work, which was significantly better than those with ORFs ( P < 0.05). Follow-up films produced no change in clinical management and cost approximately $2000/year. The prognosis for CRFs is excellent if treatment consists of appropriate pain management and pulmonary rehabilitation. We do not advocate routine follow-up CXRs in addition to physical examination for the evaluation of CRFs unless clinical deterioration is evident.
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Affiliation(s)
- Brian J. Bansidhar
- Department of Surgery and Clinical Research, Temple University/Conemaugh Memorial Medical Center, Johnstown, Pennsylvania
| | - Jorge A. Lagares-Garcia
- Department of Surgery and Clinical Research, Temple University/Conemaugh Memorial Medical Center, Johnstown, Pennsylvania
| | - S.L. Miller
- Department of Surgery and Clinical Research, Temple University/Conemaugh Memorial Medical Center, Johnstown, Pennsylvania
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Lardinois D, Krueger T, Dusmet M, Ghisletta N, Gugger M, Ris HB. Pulmonary function testing after operative stabilisation of the chest wall for flail chest. Eur J Cardiothorac Surg 2001; 20:496-501. [PMID: 11509269 DOI: 10.1016/s1010-7940(01)00818-1] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE This is a prospective evaluation of chest wall integrity and pulmonary function in patients with operative stabilisation for flail chest injuries. METHODS From 1990 to 1999, 66 patients (56 men, 10 women; mean age 52.6 years) with antero-lateral flail chest (> or =4 ribs fractured at > or =2 sites) underwent surgical stabilisation using reconstruction plates. Clinical assessment and pulmonary function testing were performed at 6 months following surgery. RESULTS Fifty-five (83%) patients had various combinations of injuries of the thorax, head, abdomen and extremities. Sixty-three (95.5%) patients underwent unilateral and 3 (4.5%) patients bilateral stabilisation with a median delay of 2.8 days (range 0-21 days) from admission. The 30-day mortality was 11% (seven of 66 patients). Immediate postoperative extubation was feasible in 31 of 66 patients (47%) and extubation within 7 days following stabilisation in 56 of 66 patients (85%). No plate dislocation was observed during the follow-up. The shoulder girdle function was intact in 51 of 57 patients (90%). Chest wall complaints were noted in 6 of 57 (11%) patients, requiring removal of implants in three cases. All patients returned to work within a mean period of 8 (range 3-16) weeks following discharge. Pulmonary function testing (n=50) at 6 months after the operation revealed a significant difference of predicted vs. recorded vital capacity (VC) and forced expiratory volume in 1s (FEV1) (P=0.04 and P=0.0001, respectively; Wilcoxon signed-rank test). The median ratio of the recorded and predicted total lung capacity (TLC) was shown to be significantly higher than 0.85 (P=0.0002; Wilcoxon signed-rank test), indicating prevention of pulmonary restriction. CONCLUSION Antero-lateral flail chest injuries accompanied by respiratory insufficiency can be effectively stabilised using reconstruction plates. Early restoration of the chest wall integrity and respiratory pump function may be cost effective through the prevention of prolonged mechanical ventilation and restriction-related working incapacity.
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Affiliation(s)
- D Lardinois
- Division of Thoracic Surgery, University Hospital of Berne, Berne, Switzerland
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Reed RL. Lung Infections and Trauma. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
This article has described the physiologic impact of trauma- and burn-related pain as well as the effect of a clinician's choice of analgesic method, using the specific example of regional analgesia for pain caused by chest trauma. It has been observed that trauma exerts a holistic influence upon the organism, marshalling reflexes, multi-system physiologic stress responses, and psychologic responses--some adaptive and others maladaptive. There is reason to consider that timely analgesia can intervene in this dynamic process and interdict the establishment of a debilitated state. A key finding of these studies is that a report of pain relief may not be the best outcome measure since the choice of analgesic method(s) has a significant impact on the secondary effects of pain. Although extrapolated from studies of perioperative pain, findings do suggest that there may be a critical period of time during which the secondary effects of a painful stimulus may be attenuated or reversed. How long this period of reversibility exists has not been determined, so planning for the level and goals of analgesia intervention should occur early on. Analgesia should be viewed not only as a humanitarian gesture, but also a therapeutic maneuver with the goal being the early restoration of function and the mitigation of a chronic debilitated state. There is scattered evidence that regional analgesic techniques using local anesthetics have some advantages over other analgesic modalities, particularly in the trauma patient with pulmonary compromise; however, as with other medical interventions, one should develop a strategic plan of application which includes consideration of potential complications and side effects, in addition to the potential therapeutic effects. The traumatized body, as well as the attending physician, must deal with inflammation, the neurohumoral reaction, musculoskeletal reflex responses, and numerous other reactions designed to stabilize an acutely destabilized systemic entity. Multimodal analgesia, with the balanced use of systemic and regional medications, has given the best short- and long-term results in studies of postthoracotomy pain. The use of a similar combined plan for posttraumatic analgesia seems logical; however, many questions remain as yet unanswered. In particular, what are the optimal combinations of techniques/medications to employ to maximize analgesia and minimize secondary effects of trauma? Can an aggressive multimodal approach intervene effectively in the development of chronic pain states, and if so, for how long? What are the long-term benefits to be derived from making a significant impact on the stress response? Last, but not least, can analgesic interventions be shown to be cost-effective according to current societal pressures to reduce the cost of health care? These and other questions are not easy to answer. Trauma strikes, in a variable fashion, patients of all ages, with all forms of comorbidity, and is treated by a technology that continues to evolve. Previous research related to the effects of analgesic treatments has been hampered by the limitations that arise when isolated groups embark on vast projects with limited numbers of patients available. It is time for investigators at multiple centers to embark on coordinated efforts to address long-term questions related to trauma and the therapeutic efficacy of analgesia.
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Affiliation(s)
- R Hedderich
- Department of Anesthesiology and Pain Medicine, Wellmont Holston Valley Medical Center, Kingsport, Tennessee, USA
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