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Peuker F, Hoepelman RJ, Beeres FJP, Balogh ZJ, Beks RB, Sweet AAR, IJpma FFA, Lansink KWW, van Wageningen B, Tromp TN, Minervini F, van Veelen NM, Hoogendoorn JM, de Jong MB, van Baal MCPM, Leenen LPH, Groenwold RHH, Houwert RM. Nonoperative treatment of multiple rib fractures, the results to beat: International multicenter prospective cohort study among 845 patients. J Trauma Acute Care Surg 2024; 96:769-776. [PMID: 37934655 DOI: 10.1097/ta.0000000000004183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Optimal treatment (i.e., nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment. METHODS The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with 1-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life. RESULTS Mean age was 57.7 ± 17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n = 13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic nonunion. The median HLOS was 7 days (4-13 days), and median intensive care unit length of stay was 2 days (1-5 days). Mean 5-Level Quality of Life Questionnaire index value was 0.83 ± 0.18 1 year after trauma. Polytrauma patients had a median HLOS of 10 days (6-18 days), a pneumonia rate of 17.6% (n = 77) and mortality rate of 1.7% (n = 7). Elderly patients (≥65 years) had a median HLOS of 9 days (5-15 days), a pneumonia rate of 19.7% (n = 57) and mortality rate of 4.1% (n = 12). CONCLUSION Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after 1 year. Future studies evaluating the benefit of operative stabilization should use contemporary outcomes to establish the therapeutic margin of rib fixation. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Felix Peuker
- From the Department of Trauma Surgery (F.P., R.J.H., A.A.R.S., M.B.J., M.B., L.P.H.L., R.M.H.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Orthopedic and Trauma Surgery (F.P., F.J.P.B., N.M.V.), Cantonal Hospital Lucerne, Lucerne, Switzerland; Department of Traumatology (Z.J.B.), John Hunter Hospital & University of Newcastle, Newcastle, New South Wales, Australia; Department of Trauma Surgery (F.F.A.I.), University Medical Center Groningen, Groningen; Department of Trauma Surgery (K.W.W.L.), Elisabeth TweeSteden Hospital, Tilburg; Department of Trauma Surgery (B.W., T.N.T.), Radboud University Medical Center, Nijmegen, The Netherlands; Department of Thoracic Surgery (F.M.), Cantonal Hospital Lucerne, Lucerne, Switzerland; Department of Trauma Surgery (J.M.H.), Haaglanden Medical Center, The Hague; Department of Clinical Epidemiology (R.H.H.G.), and Department of Biomedical Data Sciences (R.H.H.G.), Leiden University Medical Center, Leiden, The Netherlands
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Buchholz CJ, D'Aquila ML, Lollar DI. External validation of novel Revised Intensity Battle Score and comparison of static rib fracture scoring systems. J Trauma Acute Care Surg 2024; 96:466-470. [PMID: 37966462 DOI: 10.1097/ta.0000000000004199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
BACKGROUND This study aims to compare and externally validate the previously developed Revised Intensity Battle Score (RIBS) against other proposed scores for predicting poor outcomes after rib fractures. METHODS An external validation set was assembled retrospectively, comprising 1,493 adult patients with one or more rib fractures admitted to a Level 1 trauma center between 2019 and 2022. The following rib fracture scores were calculated for each patient: RIBS, Injury Severity Score, Rib Fracture Score, Chest Trauma Score, and Battle score. Each was investigated to assess utility in predicting mortality, intensive care unit upgrade, unplanned intubation and ventilator days. Performance was measured by area under the receiver operating characteristic curve. RESULTS Of the 1,493 patients who met inclusion criteria, 239 patients (16%) experienced one of more of the investigated outcomes. Generally, scores performed best at predicting mortality and ventilator days. The RIBS stood out as best predicting "any complication" (AUC = 0.735) and ">7 ventilator days" (AUC = 0.771). CONCLUSION The RIBS represents an externally validated triage score in patients with rib fractures and compares favorably to other static scoring systems. Use of this score as a triage tool may allow stratifying patients who may benefit from direct intensive care unit admission, neuraxial anesthesia and aggressive respiratory care. Next steps include prospective investigation of how pairing these interventions with score directed triage impacts outcomes. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Carl J Buchholz
- From the Department of General Surgery (C.J.B.), Virginia Tech School of Medicine-Carilion Clinic; Virginia Tech Carilion School of Medicine (M.L.D.); Department of Trauma and Acute Care Surgery (D.I.L.); and Virginia Tech Carilion School of Medicine, Carilion Clinic, Blacksburg, Virginia
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Fitzgerald CA, Cao S, Zone AI, Dultz LA, Prince H, Wan B, Alexander JC, Gasanova I, Dumas RP. Comparison of Erector Spinae Plane Blocks Versus Multimodal Pain Management for Traumatic Rib Fractures: A Matched Cohort Study. J Surg Res 2024; 294:122-127. [PMID: 37866067 DOI: 10.1016/j.jss.2023.09.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/14/2023] [Accepted: 09/24/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Erector spinae plane blocks (ESPBs) are frequently utilized when treating patients with multiple rib fractures. While previous work has demonstrated the efficacy of ESPB as an adequate method of pain control, there has been no work comparing a continuous ESPB to "best practice" multimodal pain control. We hypothesize that a continuous ESPB catheter combined with a multimodal pain regimen may be associated with a decrease in opioid requirements when compared to a multimodal pain regimen alone. METHODS This was a retrospective observational cohort study at a level 1 trauma center from September 2016 through September 2021. Inclusion criteria included patients 18 y or older with at least three unilateral rib fractures who were not mechanically ventilated during admission. The primary outcome was the total morphine equivalents utilized throughout the index admission. RESULTS A total of 142 patients were included in this study, 71 in each cohort. Patients included had a mean age of 52.5 y, and 18% were female. Demographic data including injury severity score, total number of rib fractures, and length of stay were similar. While there was a trend toward a decrease in morphine equivalents in the patient cohort undergoing ESPB catheter placement, this was not found to be statistically significant (284.3 ± 244.8 versus 412.6 ± 622.2, P = 0.5). CONCLUSIONS While ESPB catheters are frequently utilized for analgesia in the setting of multiple rib fractures, there was no decrease in total opioid usage when compared with patients who were managed with a multimodal pain regimen alone. Further assessment comparing ESPB catheters to best practice multimodal pain control regimens through a prospective, multicenter trial is required to further validate these findings.
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Affiliation(s)
- Caitlin A Fitzgerald
- Division of Trauma and Acute Care Surgery, Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Sarah Cao
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Alea I Zone
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Linda A Dultz
- Division of Burns, Trauma, Acute and Critical Care Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hillary Prince
- Division of Burns, Trauma, Acute and Critical Care Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bingchun Wan
- Division of Burns, Trauma, Acute and Critical Care Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John C Alexander
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Irina Gasanova
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ryan P Dumas
- Division of Burns, Trauma, Acute and Critical Care Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
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Intepe OG, Guner Akbiyik A. Single-Center Experience in Cases With Rib Fractures: When To Be Alert? Cureus 2023; 15:e50060. [PMID: 38186497 PMCID: PMC10769462 DOI: 10.7759/cureus.50060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/09/2024] Open
Abstract
AIM The aim of this study was to evaluate rib fracture-related complications in blunt chest traumas. METHODOLOGY The study included a cohort of 132 male and 42 female patients, aged between 22 and 89 years, all diagnosed with rib fractures subsequent to blunt chest trauma. The data collection period extended from November 2017 to November 2019. Pulmonary complications, including pneumothorax, hemothorax, pulmonary contusion, flail chest, and the need for mechanical ventilator support, were retrospectively evaluated based on age, gender, trauma history, bilateral fractures, the number of fractured ribs, and concomitant traumas in other systems. Patients with one or two fractured ribs were included in Group 1, while those with three or more rib fractures were in Goup 2. RESULTS Patients in Group 2 (n=82) had a significantly higher mean age and complication rate compared to patients in Group 1 (56.24 vs. 51.08; p: 0.033; p=0.000). Falls from height were the most common trauma history. The most frequently broken ribs were the fifth right (n=35) and the ninth right ribs (n=35), followed by the seventh right (n=33) and the seventh left rib (n=32) in order. Pneumothorax was diagnosed in 60 patients (34.4%), hemothorax in 48 patients (27.5%), and pulmonary contusion in 22 patients (12.6%). Seven patients had a flail chest (4.0%) and four required mechanical ventilation support. The number of male patients was significantly higher (p=0.000). Motor vehicle accidents were most correlated with complications in trauma history (p=0.002). Elderly age, bilateral fractures, three or more fractured ribs, and the mechanism of trauma were significantly correlated with complications (p < 0.05). The mortality rate was 0%. CONCLUSION Three or more fractured ribs, bilateral fractures, and high-energy traumas are important risk factors, particularly in the elderly population. For patients meeting these criteria, hospitalization and careful observation are recommended.
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Affiliation(s)
- Omer Giray Intepe
- Thoracic Surgery, Republic of Türkiye Ministry of Health, Ali Osman Sonmez Oncology Hospital, Bursa, TUR
| | - Ayten Guner Akbiyik
- Thoracic Surgery, Republic of Türkiye Ministry of Health, Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, TUR
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Bauman ZM, Khan H, Cavlovic L, Raposo-Hadley A, Todd SJ, King T, Cahoy K, Kamien A, Cemaj S, Sheppard O, Matos M, Berning B, Evans CH, Cantrell E. Surgical stabilization of rib fractures is associated with better return on investment for a health care institution than nonoperative management. J Trauma Acute Care Surg 2023; 95:885-892. [PMID: 37710365 DOI: 10.1097/ta.0000000000004139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRFs) continues to gain popularity due to patient benefits. However, little has been produced regarding the economic benefits of SSRF and its impact on hospital metrics such as Vizient. The aim of this study was to explore these benefits hypothesizing SSRF will demonstrate positive return on investment (ROI) for a health care institution. METHODS This is a retrospective review of all rib fracture patients over 5 years at our Level I trauma center. Patients were grouped into SSRF versus nonoperative management. Basic demographics were obtained including case mix index (CMI). Outcomes included narcotic requirements in morphine milliequivalents prior to discharge, mortality, and discharge disposition. Furthermore, actual hospital length of stay (ALOS) versus Vizient expected length of stay were compared between cohorts. Contribution margin (CM) was also calculated. Independent t-test, paired t-test, and linear regression analysis were performed, and significance set at p < 0.05. RESULTS A total of 1,639 patients were included; 230 (14%) underwent SSRF. Age, gender, and Injury Severity Score were similar. Surgical stabilization of rib fracture patients had more ribs fractured (7 vs. 4; p < 0.001) and more patients with flail chest (43.5% vs. 6.7%; p < 0.001). Surgical stabilization of rib fracture patients also had a significantly higher CMI (4.33 vs. 2.78; p = 0.001). Narcotic requirements and mortality were less in the SSRF cohort; 155 versus 246 morphine milliequivalents ( p < 0.001) and 1.7% versus 7.1% ( p = 0.003), respectively. Surgical stabilization of rib fracture patients were more likely to be discharged home (70.4% vs. 63.7%; p = 0.006). Surgical stabilization of rib fracture patients demonstrated shorter ALOS where nonoperative management patients demonstrated longer ALOS compared with Vizient expected length of stay. Contribution margins for SSRF patients were significantly higher and linear regression analysis showed a CM $1,128.14 higher per patient undergoing SSRF ( p < 0.001). CONCLUSION Patients undergoing SSRF demonstrate a significant ROI for a health care organization. Despite SSRF patients having a higher CMI, they were able to be discharged sooner than expected by Vizient calculations resulting in better a CM. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Zachary M Bauman
- From the Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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Lagazzi E, Argandykov D, de Roulet A, Proaño-Zamudio JA, Romijn ASC, Abiad M, Rafaqat W, Velmahos GC, Hwabejire JO, Paranjape CN. Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis. J Trauma Acute Care Surg 2023; 95:846-854. [PMID: 37822127 DOI: 10.1097/ta.0000000000004100] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Early surgical stabilization of rib fractures (SSRF) is associated with improved inpatient outcomes in patients with multiple rib fractures. However, there is still a paucity of data examining the optimal timing of SSRF in patients with concomitant traumatic brain injury (TBI). This study aimed to assess whether earlier SSRF was associated with improved outcomes in patients with multiple rib fractures and TBI. METHODS We performed a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program 2017-2020, including adult patients with TBI and multiple rib fractures who had undergone SSRF. The outcomes were post-procedural length of stay (LOS), hospital LOS, intensive care unit (ICU) LOS, in-hospital mortality, ventilator days, and tracheostomy rate. Multilevel mixed-effects regression analyses accounting for patient, injury, and hospital characteristics as well as institutional SSRF volume were used to assess the association between timing to SSRF and the outcomes of interest. As a sensitivity analysis, propensity-score matching was performed to compare patients who underwent early (<72 hours) versus late SSRF (≥72 hours). RESULTS Of 1,041 patients included in this analysis, 430 (41.3%) underwent SSRF within the first 72 hours from admission. Delay to SSRF was associated with an increase in post-procedural LOS (partial regression coefficient (β) = 0.011; p = 0.036; 95% confidence interval [CI], 0.001-0.023), longer hospital LOS (β = 0.053; p < 0.001; 95% CI, 0.042-0.064), prolonged ICU LOS (β = 0.032; p < 0.001; 95% CI, 0.025-0.038), and more ventilator days (β = 0.026, p < 0.001; 95% CI, 0.020-0.032). CONCLUSION In patients with concurrent multiple rib fractures and TBI, a delay in SSRF is associated with an increase in postprocedural LOS, hospital LOS, ICU LOS, and ventilator days. These findings suggest that the early patient selection and implementation of SSRF may play a beneficial role in patients presenting with concomitant TBI and multiple rib fractures. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Emanuele Lagazzi
- From the Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery (E.L., D.A., A.d.R., J.A.P.-Z., M.A., W.R., G.C.V., J.O.H., C.N.P.), Massachusetts General Hospital, Boston, MA; Department of Surgery (E.L.), Humanitas Research Hospital, Rozzano MI, Italy; and Division of Trauma & Emergency Surgery, Department of Surgery (A.-S.C.R.), Amsterdam University Medical Center, Amsterdam, the Netherlands
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Burton KR, Magidson PD. Trauma (Excluding Falls) in the Older Adult. Clin Geriatr Med 2023; 39:519-533. [PMID: 37798063 DOI: 10.1016/j.cger.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Trauma in the older adult will increasingly become important to emergency physicians hoping to optimize their patient care. The geriatric patient population possesses higher rates of comorbidities that increase their risk for trauma and make their care more challenging. By considering the nuances that accompany the critical stabilization and injury-specific management of geriatric trauma patients, emergency physicians can decrease the prevalence of adverse outcomes.
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Affiliation(s)
- Kyle R Burton
- Department of Emergency Medicine, Johns Hopkins Hospital, 1830 Eas, Monument Street, Suite 6-110, Baltimore, MD 21287, USA
| | - Phillip D Magidson
- Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Suite A150, Baltimore, MD 21224, USA.
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Buchholz CJ, Jia L, Manea C, Petersen T, Wang H, Stright A, Young J, Calland JF. Revised Intensity Battle Score (RIBS): Development of a Clinical Score for Predicting Poor Outcomes After Rib Fractures. Am Surg 2023; 89:4668-4674. [PMID: 36120831 DOI: 10.1177/00031348221123087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with rib fractures have variable clinical courses and it is difficult to predict which patients will do poorly. Ideally this prediction would happen at the time of admission to facilitate effective triage. One scoring system devised to this end, is the Battle score. This study aims to evaluate the efficacy of the Battle score as triage tool, and to re-tool it for performance in an inpatient trauma setting. METHODS A multivariate logistic regression model was trained on patients admitted to a level one trauma center with at least one rib fracture. A composite outcome was used to classify those who had poor outcomes. Eighteen candidate predictors were analyzed in univariate analysis, then the most promising fed into the logistic model until a triage score was built and internally validated by bootstrapping. RESULTS Of the 838 patients who met the inclusion criteria, 145 (17.3%) patients had a defined poor outcome. The relevant predictors included in the final scoring system were number of ribs fractured, chest tube, pulmonary contusions, chronic obstructive pulmonary disease, and Glasgow coma score. Age was not found to be predictive. This score was found to have higher fidelity in predicting poor outcomes than the original Battle score (AUROC .858 vs .649.). DISCUSSION An easy to calculate clinical scoring system was created to triage patients with rib fractures at the time of admission. Age may be of less importance than previously thought, while injury burden and history of lung disease may play a larger role.
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Affiliation(s)
- Carl J Buchholz
- Department of Surgery, Virginia Tech Carilion Clinic, Roanoke VA, USA
| | - Leon Jia
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Calin Manea
- Department of General Surgery, Wellspan Health York Hospital, York, PA, USA
| | - Taylor Petersen
- Department of Pediatrics, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Haowei Wang
- Department of Surgery, Strong Memorial Hospital, Rochester, NY, USA
| | - Adam Stright
- Department of Trauma and Acute Care Surgery, NYU Langone Health, New York, NY, USA
| | - Jeffrey Young
- University of Virginia Health System, Charlottesville VA, USA
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Schmelzer K, Ziegenhain F, Canal C, Pape HC, Neuhaus V. [Bilateral thoracic trauma-"double the trouble"?]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:789-795. [PMID: 37268786 PMCID: PMC10447262 DOI: 10.1007/s00104-023-01891-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma. OBJECTIVE The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two. MATERIAL AND METHODS In a retrospective study, data from all patients diagnosed with thoracic trauma at a level I trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome. RESULTS A total of 714 patients were included in the analysis. The mean Injury Severity Score (ISS) was 19. Patients with an additional thoracic spine injury had a significantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for a chest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors. CONCLUSION Patients with bilateral chest trauma had an increased incidence of complications and a higher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.
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Affiliation(s)
- Katharina Schmelzer
- Chirurgische Klinik, Kantonsspital Glarus (KSGL), Burgstr. 99, 8750, Glarus, Schweiz
| | - Franziska Ziegenhain
- Klinik für Traumatologie, Universitätsspital Zürich (USZ), Universität Zürich (UZH), Rämistr. 100, 8091, Zürich, Schweiz
| | - Claudio Canal
- Klinik für Traumatologie, Universitätsspital Zürich (USZ), Universität Zürich (UZH), Rämistr. 100, 8091, Zürich, Schweiz
| | - Hans-Christoph Pape
- Klinik für Traumatologie, Universitätsspital Zürich (USZ), Universität Zürich (UZH), Rämistr. 100, 8091, Zürich, Schweiz
| | - Valentin Neuhaus
- Klinik für Traumatologie, Universitätsspital Zürich (USZ), Universität Zürich (UZH), Rämistr. 100, 8091, Zürich, Schweiz.
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Liu HY, Lin TH, Chen KC, Hsiao WL, Hu RH, Liao HC. Comparison between non-surgical and surgical management of rib fractures in major trauma patients without brain injuries. Am J Surg 2023; 226:350-355. [PMID: 37263888 DOI: 10.1016/j.amjsurg.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND This study aimed to evaluate the different outcomes between the non-surgical and surgical groups in patients with major trauma without brain injuries. METHODS This study prospectively collected data from patients with traumatic rib fractures without brain injuries from June 2017 to November 2019. The primary outcomes were the pain score at admission and discharge and the length of hospital stay. We performed multiple regression analysis to compare the outcomes and surgical risk as the severity of chest trauma between both groups. RESULTS Fifty-three patients were enrolled. There was no statistically significant difference in baseline characteristics between both groups. However, the surgical group had more severe chest trauma than the non-surgical group. After the analysis, the pain score improved significantly in the surgical group. The hospital stay of the surgical group was four days shorter than that of the non-surgical group, and there was severe chest trauma in the surgical group. CONCLUSIONS Surgical management of rib fractures can reduce pain and hospital stay in major trauma patients.
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Affiliation(s)
- Hao-Yun Liu
- Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Tzu-Hsin Lin
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ke-Cheng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Ling Hsiao
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Rey-Heng Hu
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsien-Chi Liao
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan.
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Butterfield JH, Reparaz LB, Watson CM. Cryoablation versus rib plating: Is the real problem pain control or chest wall instability? Trauma Case Rep 2023; 46:100858. [PMID: 37347011 PMCID: PMC10279898 DOI: 10.1016/j.tcr.2023.100858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2023] [Indexed: 06/23/2023] Open
Affiliation(s)
- Jaron H. Butterfield
- Corresponding author at: 925 Native Rye Way, Columbia, SC 29073, United States of America.
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Field F, Olsson J, Hurley A. Alcohol Dependence and Rib Fracture Outcomes: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e42639. [PMID: 37644941 PMCID: PMC10461216 DOI: 10.7759/cureus.42639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 08/31/2023] Open
Abstract
Chronic alcohol use has been associated with impaired pulmonary function, increased risk of pneumonia and poor outcomes after trauma. With a high incidence of rib fractures in this population, the clinical and physiological factors associated with alcohol dependence may influence how these patients recover from thoracic injuries. Therefore, the aim of the systematic review was to examine the effect of alcohol dependence on rib fracture outcomes. The Embase, PubMed and Web of Science databases were searched for studies examining adult patients with rib fractures, with and without a history of alcohol dependency. The outcomes of interest were mortality, pulmonary complications, intensive care length of stay, ventilator days and hospital length of stay. A meta-analysis was performed to combine the data and compare results. Three studies met the criteria for inclusion in the review and all studies were observational in design. Alcohol dependency was associated with increased mortality (OR 1.44 (95% CI: 1.33-1.56)), pneumonia (OR 2.14 (2.02-2.27)) and ARDS (OR 1.71(1.48-1.98)) as well as longer stays in hospital and intensive care (p<0.05). No difference was found in ventilator days between the two groups. Early intensive care review should be considered to reduce complications in this population alongside prompt management of withdrawal symptoms. However, limited primary research exists on this topic and the quality of current evidence is low. Additional primary research is needed to further understand this correlation and draw meaningful conclusions.
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Affiliation(s)
- Fiona Field
- Trauma Sciences, Queen Mary University of London, London, GBR
| | - Jenny Olsson
- Anaesthetics, King's College Hospital NHS Foundation Trust, London, GBR
| | - Anna Hurley
- Plastic Surgery, Hull University Teaching Hospitals, Hull, GBR
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Lagazzi E, de Roulet A, Proaño-Zamudio JA, Argandykov D, Romijn AS, Abiad M, Rafaqat W, Hwabejire JO, Velmahos GC, Paranjape C. Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis. J Trauma Acute Care Surg 2023; 94:823-830. [PMID: 37079864 DOI: 10.1097/ta.0000000000003954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients. METHODS Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8). RESULTS Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%, p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004). CONCLUSION In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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14
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Wang N, Bachman KC, Linden PA, Ho VP, Moorman ML, Worrell SG, Argote-Greene LM, Towe CW. Age as a Barrier to Surgical Stabilization of Rib Fractures in Patients with Flail Chest. Am Surg 2023; 89:927-934. [PMID: 34732075 PMCID: PMC9061890 DOI: 10.1177/00031348211047490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Although randomized trials demonstrate a benefit to surgical stabilization of rib fractures (SSRF), SSRF is rarely performed. We hypothesized older patients were less likely to receive SSRF nationally. METHODS The 2016 National Inpatient Sample was used to identify adults with flail chest. Comorbidities and receipt of SSRF were categorized by ICD-10 code. Univariable testing and Multivariable regression were performed to determine the association of demographic characteristics and comorbidities to receipt of SSRF. RESULTS 1021 patients with flail chest were identified, including 244 (23.9%) who received SSRF. Patients ≥70 years were less likely to receive SSRF. (<70 yrs 201/774 [26.0%] vs ≥70 43/247 [17.4%], P = .006) and had higher risk of death (<70 yrs 39/774 [5.0%] vs ≥70 33/247 [13.4%], P < .001) In multivariable modeling, only age ≥70 years was associated with SSRF (OR .591, P = .005). CONCLUSION Despite guideline-based support of SSRF in flail chest, SSRF is performed in <25% of patients. Age ≥70 years is associated with lower rate of SSRF and higher risk of death. Future study should examine barriers to SSRF in older patients.
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Affiliation(s)
- Naomi Wang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Matthew L Moorman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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15
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Oppizzi G, Xu D, Patel T, Diaz JJ, Zhang LQ. Open reduction internal fixation of rib fractures: a biomechanical comparison between the RibLoc U Plus ® system and anterior plate in rib implants. Eur J Trauma Emerg Surg 2023; 49:383-391. [PMID: 36018371 PMCID: PMC10148598 DOI: 10.1007/s00068-022-02075-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/08/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In this study, we assessed the bending strength of two surgical repairs of rib fracture using RibLoc® U Plus system made by Acute Innovations and the anterior plate by Synthes. METHODS After a rib fracture was created in seven pairs of cadaveric rib specimens, one side was repaired with the anterior plate and the other side repaired with the RibLoc U Plus® plate. Each of the rib is loaded using a custom device over 360,000 bending cycles to simulate in vivo fatiguing related to respiration. Upon completion of the cyclic loading, the specimens were compressively loaded to failure and the failure bending moment was determined. RESULTS The ribs repaired with the RibLoc U Plus® system showed 79% higher failure bending moment than that of the anterior plate, with a p value of 0.033. The ribs repaired with RibLoc U Plus® showed a trend of less stiffness reduction over the 360,000 loading cycles. CONCLUSION The biomechanical study showed that the RibLoc U Plus® system is stronger in the bending moment loading of repaired ribs, possibly due to the U-shape structure supporting both the inner and outer cortices of a repaired rib.
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Affiliation(s)
- Giovanni Oppizzi
- Department of Bioengineering, University of Maryland, 3102 A. James Clark Hall, College Park, MD, 20742, USA.,Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland, 100 Penn Street, Baltimore, MD, 21201, USA
| | - Dali Xu
- Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland, 100 Penn Street, Baltimore, MD, 21201, USA
| | - Tirth Patel
- Chicago College of Osteopathic Medicine, Midwestern University, 555 31st Street, Downers Grove, IL, 60515, USA
| | - Jose J Diaz
- Department of Surgery, School of Medicine, University of Maryland, 22 S Greene Street, Baltimore, MD, 21201, USA.,Department of Orthopedics, School of Medicine, University of Maryland, 110 S. Paca Street, Baltimore, MD, 21201, USA
| | - Li-Qun Zhang
- Department of Bioengineering, University of Maryland, 3102 A. James Clark Hall, College Park, MD, 20742, USA. .,Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland, 100 Penn Street, Baltimore, MD, 21201, USA. .,Department of Epidemiology and Public Health, School of Medicine, University of Maryland, 660 W. Redwood Street, Baltimore, MD, 21201, USA. .,Department of Orthopedics, School of Medicine, University of Maryland, 110 S. Paca Street, Baltimore, MD, 21201, USA.
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16
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Macrae TA, Lazo J, Viduya J, Florez R, Dewey K, Gao Y, Singer JP, Hays SR, Golden JA, Kukreja J, Greenland JR, Calabrese DR. Frailty and genetic risk predict fracture after lung transplantation. Am J Transplant 2023; 23:214-222. [PMID: 36695698 PMCID: PMC10037703 DOI: 10.1016/j.ajt.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/15/2022] [Accepted: 11/29/2022] [Indexed: 01/07/2023]
Abstract
Fractures negatively impact quality of life and survival. We hypothesized that recipient frailty score and genetic profile measured before transplant would predict risk of fracture after lung transplant. We conducted a retrospective cohort study of bone mineral density (BMD) and fracture among lung transplant recipients at a single center. The association between predictors and outcomes were assessed by multivariable time-dependent Cox models or regression analysis. Among the 284 participants, osteoporosis and fracture were highly prevalent. Approximately 59% of participants had posttransplant osteopenia, and 35% of participants developed at least 1 fracture. Low BMD was associated with a polygenic osteoporosis risk score, and the interaction between genetic score and BMD predicted fracture. Pretransplant frailty was associated with risk for spine and hip fracture, which were not associated with chronic lung allograft dysfunction or death. Chest fractures were the most frequent type of fracture and conferred a 2.2-fold increased risk of chronic lung allograft dysfunction or death (time-dependent P < .001). Pneumonia, pleural effusions, and acute rejection frequently occurred surrounding chest fracture. Pretransplant frailty and recipient genotype may aid clinical risk stratification for fracture after transplant. Fracture carries significant morbidity, underscoring the importance of surveillance and osteoporosis prevention.
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Affiliation(s)
- Trisha A Macrae
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jose Lazo
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Judy Viduya
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Rebecca Florez
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Katherine Dewey
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Ying Gao
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jonathan P Singer
- Department of Medicine, University of California, San Francisco, California, USA
| | - Steven R Hays
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jeffrey A Golden
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California, USA
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, California, USA; Medical Service, Veterans Affairs Health Care System, San Francisco, California, USA
| | - Daniel R Calabrese
- Department of Medicine, University of California, San Francisco, California, USA; Medical Service, Veterans Affairs Health Care System, San Francisco, California, USA.
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17
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van Veelen NM, Buenter L, Kremo V, Peek J, Leiser A, Kestenholz P, Babst R, Paulus Beeres FJ, Minervini F. Outcomes after fixation of rib fractures sustained during cardiopulmonary resuscitation: A retrospective single center analysis. Front Surg 2023; 10:1120399. [PMID: 36755767 PMCID: PMC9899886 DOI: 10.3389/fsurg.2023.1120399] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/04/2023] [Indexed: 01/24/2023] Open
Abstract
Background Historically rib fractures have been typically treated non-operatively. Recent studies showed promising results after osteosynthesis of rib fractures in trauma patients with flail segments or multiple rib fractures. However, there is a paucity of data on rib fixation after cardiopulmonary resuscitation (CPR). This study evaluated the outcomes of patients who received rib fixation after CPR. Methods Adult patients who received surgical fixation of rib fractures sustained during CPR between 2010 and 2020 were eligible for inclusion in this retrospective study. Outcome measures included complications, quality of life (EQ 5D 5L) and level of dyspnea. Results Nineteen patients were included with a mean age of 66.8 years. The mean number of fractured ribs was ten, seven patients additionally had a sternum fracture. Pneumonia occurred in 15 patients (74%), of which 13 were diagnosed preoperatively and 2 post-operatively. Six patients developed a postoperative pneumothorax, none of which required revision surgery. One patient showed persistent flail chest after rib fixation and required additional fixation of a concomitant sternum fracture. One infection of the surgical site of sternal plate occurred, while no further surgery related complications were reported. Mean EQ-5D-5L was 0.908 and the average EQ VAS was 80. One patient reported persisting dyspnea. Conclusion To date, this is the largest reported cohort of patients who received rib fixation for fractures sustained during CPR. No complications associated with rib fixation were reported whereas one infection after sternal fixation did occur. Current follow-up demonstrated a good long-term quality of life after fixation, warranting further studies on this topic. Deeper knowledge on this subject would be beneficial for a wide spectrum of physicians.
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Affiliation(s)
- Nicole Maria van Veelen
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Lea Buenter
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Valérie Kremo
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jesse Peek
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Alfred Leiser
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Peter Kestenholz
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland,Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | | | - Fabrizio Minervini
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland,Correspondence: Fabrizio Minervini
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18
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Comorbidities, injury severity and complications predict mortality in thoracic trauma. Eur J Trauma Emerg Surg 2022; 49:1131-1143. [PMID: 36527498 PMCID: PMC10175434 DOI: 10.1007/s00068-022-02177-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/12/2022] [Indexed: 12/23/2022]
Abstract
Abstract
Purpose
Thoracic trauma accounts for 25–50% of posttraumatic mortality. Data on epidemiology of thoracic trauma in Scandinavia and risk factors for mortality are scarce. This study aims to provide an overview of epidemiology, clinical events and risk factors for mortality of patients with severe thoracic injuries.
Methods
A retrospective study including adult thoracic trauma patients with abbreviated injury scale ≥ 3, between 2009 and 2018 at Haukeland University Hospital was performed. Subgroup analyses were performed for specific patient groups: (1) isolated thoracic trauma, (2) polytrauma without Traumatic Brain Injury (TBI) and (3) polytrauma with TBI. Logistic regression analyses were applied to find risk factors for 30-days mortality. Age, sex, comorbidity polypharmacy score (CPS), trauma and injury severity score (TRISS) and comprehensive complication index (CI) were included in the final model.
Results
Data of 514 patients were analyzed, of which 60 (12%) patients died. Median (IQR) injury severity score (ISS) was 17 (13–27). Data of 463 patients, of which 39 patients died (8%), were included in multivariate analyses. Female sex odds ratio (OR) (2.7, p = 0.04), CPS > 9 (OR 4.8; p = 0.01), TRISS ≤ 50% (OR 44; p < 0.001) and CI ≥ 30 (OR 12.5, p < 0.001) were significant risk factors for mortality. Subgroup analyses did not demonstrate other risk factors.
Conclusion
Comorbidities and associated pharmacotherapies, TRISS, female sex, and complications during admission predict in-hospital mortality after thoracic trauma. Current findings might help to recognize patients at risk of an adverse outcome, and thereby prevent complications.
Trial registration: retrospectively registered
The regional committees for medical and health research ethics file number is 2017/293.
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19
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White L, Riley B, Seidel D, Davis K, Mitchell A, Abi-fares C, Basson W, Anstey C. Rib fracture-related morbidity and mortality for older persons in the era of fascial plane blocks: A cohort study. TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086221125725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction Analgesia is key to successful conservative, nonsurgical management of patients admitted to the hospital with multiple rib fractures. Recently, new fascial plane regional anesthesia techniques have become widely available. We hypothesized that since the introduction of these new regional analgesia techniques, for patients over the age of 65 years, the effect of increasing numbers of rib fractures has been mitigated. Methods A retrospective study of patients admitted for the management of rib fractures between 2017 and 2020 was performed. Patients not admitted to the hospital, under the age of 65 years, or with chest trauma other than rib fractures were not eligible for inclusion. The primary outcome of interest was mortality. The secondary outcomes were the incidence of pneumonia and intensive care unit admission. Results were reported as the odds ratio and its 95% confidence interval and associated p-value. Statistical significance was set at [Formula: see text] < 0.05. Results Overall, 252 patients were included and 142 patients received a regional anesthesia. The mortality rate was 4% (n = 10) with no association between mortality and number of rib fractures ( p = 0.215). Twenty-four patients (9.5%) developed pneumonia during their hospital stay, again with no association with an increasing number of rib fractures. The intensive care unit admission rate was 13.1% (n = 33) and correlated with an increasing number of fractures (odds ratio = 1.15; 95% confidence interval = 1.01 to 1.31; p = 0.038). Conclusion Management including liberal utilization of regional anesthesia for at-risk patients appears to mitigate the effect of increasing numbers of rib fractures on the incidence of mortality and pneumonia.
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Affiliation(s)
- L.D. White
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - B. Riley
- Intensive Care Department, The Alfred Hospital, Melbourne, VIC, Australia
| | - D. Seidel
- Department of Anaesthesia, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - K. Davis
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - A. Mitchell
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - C. Abi-fares
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - W. Basson
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - C. Anstey
- School of Medicine, Griffith University, Birtinya, QLD, Australia
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20
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Battle C, Carter K, Newey L, Giamello JD, Melchio R, Hutchings H. Risk factors that predict mortality in patients with blunt chest wall trauma: an updated systematic review and meta-analysis. Emerg Med J 2022; 40:369-378. [PMID: 36241371 DOI: 10.1136/emermed-2021-212184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 10/03/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Over the last 10 years, research has highlighted emerging potential risk factors for poor outcomes following blunt chest wall trauma. The aim was to update a previous systematic review and meta-analysis of the risk factors for mortality in blunt chest wall trauma patients. METHODS A systematic review of English and non-English articles using MEDLINE, Embase and Cochrane Library from January 2010 to March 2022 was completed. Broad search terms and inclusion criteria were used. All observational studies were included if they investigated estimates of association between a risk factor and mortality for blunt chest wall trauma patients. Where sufficient data were available, ORs with 95% CIs were calculated using a Mantel-Haenszel method. Heterogeneity was assessed using the I2 statistic. RESULTS 73 studies were identified which were of variable quality (including 29 from original review). Identified risk factors for mortality following blunt chest wall trauma were: age 65 years or more (OR: 2.11; 95% CI 1.85 to 2.41), three or more rib fractures (OR: 1.96; 95% CI 1.69 to 2.26) and presence of pre-existing disease (OR: 2.86; 95% CI 1.34 to 6.09). Other new risk factors identified were: increasing Injury Severity Score, need for mechanical ventilation, extremes of body mass index and smoking status. Meta-analysis was not possible for these variables due to insufficient studies and high levels of heterogeneity. CONCLUSIONS The results of this updated review suggest that despite a change in demographics of trauma patients and subsequent emerging evidence over the last 10 years, the main risk factors for mortality in patients sustaining blunt chest wall trauma remained largely unchanged. A number of new risk factors however have been reported that need consideration when updating current risk prediction models used in the ED. PROSPERO REGISTRATION NUMBER CRD42021242063. Date registered: 29 March 2021. https://www.crd.york.ac.uk/PROSPERO/%23recordDetails.
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Affiliation(s)
- Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Kym Carter
- Swansea Trials Unit, Swansea University, Swansea, UK
| | - Luke Newey
- Physiotherapy Department, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Jacopo Davide Giamello
- School of Emergency Medicine, Università degli Studi di Torino Dipartimento di Scienze Mediche, Torino, Italy.,Department of Emergency Medicine, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Remo Melchio
- Department of Internal Medicine, Santa Croce e Carle Hospital, Cuneo, Italy
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21
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McGuinness MJ, Harmston C. Management and outcomes of rib fractures in patients with isolated blunt thoracic trauma: Results of the Aotearoa New Zealand RiBZ study. Injury 2022; 53:2953-2959. [PMID: 35489820 DOI: 10.1016/j.injury.2022.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 02/02/2023]
Abstract
AIM Rib fractures are common and associated with significant morbidity and mortality. There is limited literature on patient care and outcomes in Aotearoa New Zealand (AoNZ). The aim of this study is to describe key clinical outcomes and management interventions for patients with rib fractures across AoNZ. METHODS A national prospective multicenter observational cohort study was performed. Patients admitted between 1 December 2020 and 28 February 2021 with one or more radiologically proven rib fractures and an Abbreviated Injury Score of the head or abdomen of less than 3 were included. The primary outcomes of interest were the rates of thirty-day pneumonia, re-presentation and mortality. The secondary outcomes of interest were rate of surgical stabilisation of rib fractures (SSRF) and pain management of patients with rib fractures. Binomial logistic regression was performed for the primary outcomes and funnel plots were created of the inter-hospital variation in pneumonia. RESULTS Fourteen AoNZ hospitals and 407 patients were included. Mean age was 57.4 (SD 18.7), 28% were female, 15% Māori and 85% non-Māori. The median number of rib fractures was 4. The rate of pneumonia, re-presentation and mortality was 11%, 8% and 2%, respectively. Logistic regression found the odds of pneumonia increased with each additional rib fracture (OR 1.15 95% CI 1.05-1.25) and the odds of re-presentation increased with age (OR 1.028 95% CI 1.005-1.051) and Māori ethnicity (OR 2.754 95% CI 1.077-7.045). The funnel plot of inter-hospital variation in pneumonia rate adjusted for clinically plausible variables found no centre lay outside the 95% confidence interval. SSRF was performed in 2% of patients. 58% of patients had a pain team review and 23% a regional block. CONCLUSION This study describes clinical outcomes for patients with isolated rib fractures from multiple hospitals in AoNZ. A moderate pneumonia rate of 11% was found which is likely amendable to reduction with quality improvement initiatives. Consideration should be given to further resource and improve the access to SSRF and regional analgesia given the low utilization found across AoNZ. A higher re-presentation rate in Māori and elderly patients was found which needs further investigation.
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Affiliation(s)
- Matthew J McGuinness
- University of Auckland; Surgical Department, Whangārei Hospital, Manu Road, Whangārei, New Zealand.
| | - Christopher Harmston
- University of Auckland; Surgical Department, Whangārei Hospital, Manu Road, Whangārei, New Zealand
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22
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Curtis K, Kourouche S, Asha S, Buckley T, Considine J, Middleton S, Mitchell R, Munroe B, Shaban RZ, Lam M, Fry M. Effect of an intervention for patients 65 years and older with blunt chest injury: Patient and health service outcomes. Injury 2022; 53:2939-2946. [PMID: 35644642 DOI: 10.1016/j.injury.2022.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/05/2022] [Accepted: 04/29/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Blunt chest injury in older adults, aged 65 years and older, leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes in older adults with blunt chest injury. METHODS ChIP comprised multidimensional implementation guidance in three key pillars of care for blunt chest injury: respiratory support, analgesia, and complication prevention. Implementation was guided using the Behaviour Change Wheel. This proof-of-concept controlled pre- and post-test study with two intervention and two control sites in Australia was conducted from July 2015 to June 2019. The primary outcomes were non-invasive ventilation (NIV) use, unplanned Intensive Care Unit (ICU) admissions, and in-hospital mortality. Secondary outcomes were health service and costing outcomes. RESULTS There were 1122 patients included in the analysis, with 673 at intervention sites (331 pre-test and 342 post-test) and 449 at control sites (256 pre-test and 193 post-test). ChIP was associated with unplanned ICU admissions and in NIV use with a reduction of the odds in the post vs the pre periods in the intervention sites when compared to the controls (ratio of OR=0.13, 95%CI=0.03-0.55) and (ratio of OR=0.14, 95%CI=0.02-0.98) respectively. There was no significant change in mortality. Implementing ChIP was also associated with health service team reviews with an increased odds in the post vs pre periods in the intervention sites in comparison to the controls for surgical review (ratio of OR =6.93, 95%CI=4.70-10.28), ICU doctor (ratio of OR =5.06, 95%CI=2.26-9.25), ICU liaison (ratio of OR =14.14, 95%CI=3.15-63.31), and pain (ratio of OR =5.59, 95%CI=3.25-9.29). ChIP was also related to incentive spirometry (ratio of OR=6.35, 95%CI= 3.15-12.82) and overall costs (ratio of mean ratio=1.34, 95%CI=1.09-1.66) with a higher ratio for intervention sites. CONCLUSION Implementation of ChIP using the Behaviour Change Wheel was associated with reduced unplanned ICU admissions and NIV use and improved health care delivery. TRIAL REGISTRATION ANZCTR: ACTRN12618001548224, approved 17/09/2018.
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia; Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Northfields Avenue, Wollongong NSW, Australia.
| | - Sarah Kourouche
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
| | - Stephen Asha
- Emergency Department, St George Hospital, Kogarah, NSW, Australia; St George Clinical School, Faculty of Medicine, University of New South Wales, NSW, Australia.
| | - Thomas Buckley
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia.
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Experience in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia; Centre for Quality and Patient Safety Experience, Eastern Health Partnership, Box Hill, VIC, Australia.
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; Australian Catholic University, NSW Australia.
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW 2113, Australia.
| | - Belinda Munroe
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia.
| | - Ramon Z Shaban
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW 2006, Australia; Division of Infectious Diseases and Sexual Health, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, 2145, Australia; New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, NSW, 2145, Australia.
| | - Mary Lam
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia.
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia; University of Technology Sydney, Faculty of Health, NSW, Australia; Northern Sydney Local Health District, NSW, Australia.
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Narsule CK, Mosenthal AC. Is There a Role for Rib Plating in Thoracic Trauma? Adv Surg 2022; 56:321-335. [PMID: 36096575 DOI: 10.1016/j.yasu.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Rib fractures are a morbid consequence of blunt trauma and are associated with a highly variable clinical presentation ranging from nondisplaced rib fractures causing limited, manageable pain to severely displaced rib fractures with concomitant thoracic injuries leading to respiratory failure. Due to an evolution of techniques, hardware technology, and general acceptance, rib plating has increased substantially at trauma centers all throughout the United States over the past decade. This article aims to review the most recent and current reports for rib plating with respect to indications, preoperative evaluation and imaging, approaches, timing for intervention, outcomes in patients with flail chest and nonflail injuries, and the management of complications. From these data, it becomes clear that the surgical stabilization of rib fractures (SSRF) has a firm place in the management of thoracic trauma.
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Affiliation(s)
- Chaitan K Narsule
- Department of Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
| | - Anne C Mosenthal
- Department of Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
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24
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Kyriakakis R, Johnson B, Krech L, Pounders S, Lypka M, Chapman A, Valdez C. Planning for the Worst: The impact of a comprehensive, risk associated treatment protocol on unanticipated ICU admissions in patients affected by rib fractures. Am J Surg 2022; 224:602-606. [DOI: 10.1016/j.amjsurg.2022.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
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Intravenous Lidocaine for the Management of Traumatic Rib Fractures: A Double-Blind Randomized Controlled Trial (INITIATE Program of Research). J Trauma Acute Care Surg 2022; 93:496-502. [PMID: 35137728 DOI: 10.1097/ta.0000000000003562] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Traumatic rib fractures (TRFs) are common with a 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and death. Evidence exists for intravenous (IV) lidocaine's effectiveness and safety in post-operative thoracic and abdominal surgery and we hypothesized it would be effective in patients with TRFs. METHODS We conducted a single-centre, double-blind, randomized control trial comparing IV lidocaine plus usual analgesics to placebo infusion plus usual analgesics for 72-96 hours. Participants were adult trauma patients diagnosed with two or more TRFs requiring hospital admission. The primary outcome was mean pain score at rest and with movement, as measured on the Visual Analog Scale (VAS). Secondary outcomes included patient satisfaction and opioid requirements (standardized total morphine equivalents (TME)). The study was powered to detect a 20% reduction in pain scores, which has been deemed clinically meaningful. RESULTS 36 patients were enrolled and randomized to IV lidocaine or placebo. Comparison of the mean VAS pain scores demonstrated significant pain reduction with movement in the lidocaine group compared to placebo (7.05 ± 1.72 vs 8.22 ± 1.28, p = 0.042). Although pain scores at rest were reduced in the lidocaine group, this difference was not statistically significant (3.37 ± 2.00 vs 3.82 ± 1.97, p = 0.519). Patient satisfaction was higher in the lidocaine group than the placebo group, though this did not reach statistical significance (8.3 (IQR 7.0, 9.6) vs 6.3 (IQR 5.2, 7.1), p = 0.105). TMEs were lower in the lidocaine group than the placebo group, but this difference did not reach statistical significance (167 (IQR 60, 340) vs 290 (IQR 148, 390), p = 0.194). CONCLUSIONS These results demonstrate that lidocaine has a beneficial analgesic effect in patients with TRFs. Future work is needed to evaluate lidocaine's ability to reduce patient important consequences of inadequate analgesia. LEVEL OF EVIDENCE Level 2: RCT with significance and only 1 negative criterion (Missing >20% data).
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26
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Heindel P, Ordoobadi A, El Moheb M, Serventi-Gleeson J, Garvey S, Heyman A, Patel N, Sanchez S, Kaafarani HMA, Herrera-Escobar J, Salim A, Nehra D. Patient-reported outcomes 6 to 12 months after isolated rib fractures: A nontrivial injury pattern. J Trauma Acute Care Surg 2022; 92:277-286. [PMID: 34739001 DOI: 10.1097/ta.0000000000003451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite the ubiquity of rib fractures in patients with blunt chest trauma, long-term outcomes for patients with this injury pattern are not well described. METHODS The Functional Outcomes and Recovery after Trauma Emergencies (FORTE) project has established a multicenter prospective registry with 6- to 12-month follow-up for trauma patients treated at participating centers. We combined the FORTE registry with a detailed retrospective chart review investigating admission variables and injury characteristics. All trauma survivors with complete FORTE data and isolated chest trauma (Abbreviated Injury Scale score of ≤1 in all other regions) with rib fractures were included. Outcomes included chronic pain, limitation in activities of daily living, physical limitations, exercise limitations, return to work, and both inpatient and discharge pain control modalities. Multivariable logistic regression models were built for each outcome using clinically relevant demographic and injury characteristic univariate predictors. RESULTS We identified 279 patients with isolated rib fractures. The median age of the cohort was 68 years (interquartile range, 56-78 years), 59% were male, and 84% were White. Functional and quality of life limitations were common among survivors of isolated rib fractures even 6 to 12 months after injury. Forty-three percent of patients without a preexisting pain disorder reported new daily pain, and new chronic pain was associated with low resilience. Limitations in physical functioning and exercise capacity were reported in 56% and 51% of patients, respectively. Of those working preinjury, 28% had not returned to work. New limitations in activities of daily living were reported in 29% of patients older than 65 years. Older age, higher number of rib fractures, and intensive care unit admission were independently associated with higher odds of receiving regional anesthesia. Receiving a regional nerve block did not have a statistically significant association with any patient-reported outcome measures. CONCLUSION Isolated rib fractures are a nontrivial trauma burden associated with functional impairment and chronic pain even 6 to 12 months after injury. LEVEL OF EVIDENCE Prognostic/epidemiologic, level III.
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Affiliation(s)
- Patrick Heindel
- From the Division of Trauma, Burn and Surgical Critical Care, Department of Surgery (P.H., A.O., M.E.M., A.S.), and Center for Surgery and Public Health (P.H., A.O., M.E.M., J.S.-G., S.G., A.H., N.P., J.H.E., A.S., D.N.), Brigham and Women's Hospital, Harvard Medical School; Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery (S.S.), Boston University School of Medicine, Boston, Massachusetts; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery (H.M.A.K.), Massachusetts General Hospital, Harvard Medical School; and Division of Trauma, Burn and Critical Care Surgery, Department of Surgery (D.N.), University of Washington Medical Center, Seattle, Washington
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27
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Rosen JE, Bulger EM, Cuschieri J. Respiratory events after intensive care unit discharge in trauma patients: Epidemiology, outcomes, and risk factors. J Trauma Acute Care Surg 2022; 92:28-37. [PMID: 34284468 PMCID: PMC8692327 DOI: 10.1097/ta.0000000000003362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Respiratory complications are associated with significant morbidity and mortality in trauma patients. The care transition from the intensive care unit (ICU) to the acute care ward is a vulnerable time for injured patients. There is a lack of knowledge about the epidemiology of respiratory events and their outcomes during this transition. METHODS Retrospective cohort study in a single Level I trauma center of injured patients 18 years and older initially admitted to the ICU from 2015 to 2019 who survived initial transfer to the acute care ward. The primary outcome was occurrence of a respiratory event, defined as escalation in oxygen therapy beyond nasal cannula or facemask for three or more consecutive hours. Secondary outcomes included unplanned intubation for a primary pulmonary cause, adjudicated via manual chart review, as well as in-hospital mortality and length of stay. Multivariable logistic regression was used to examine patient characteristics associated with posttransfer respiratory events. RESULTS There were 6,561 patients that met the inclusion criteria with a mean age of 52.3 years and median Injury Severity Score of 18 (interquartile range, 13-26). Two hundred and sixty-two patients (4.0%) experienced a respiratory event. Respiratory events occurred early after transfer (median, 2 days, interquartile range, 1-5 days), and were associated with high mortality (16% vs. 1.8%, p < 0.001), and ICU readmission rates (52.6% vs. 4.7%, p < 0.001). Increasing age, male sex, severe chest injury, and comorbidities, including preexisting alcohol use disorder, congestive heart failure, and chronic obstructive pulmonary disease, were associated with increased odds of a respiratory event. Fifty-eight patients experienced an unplanned intubation for a primary pulmonary cause, which was associated with an in-hospital mortality of 39.7%. CONCLUSION Respiratory events after transfer to the acute care ward occur close to the time of transfer and are associated with high mortality. Interventions targeted at this critical time are warranted to improve patient outcomes. LEVEL OF EVIDENCE Prognostic and Epidemiological study, level III.
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Affiliation(s)
- Joshua E Rosen
- From the Surgical Outcomes Research Center, Department of Surgery (J.E.R.), University of Washington; Department of Surgery (J.E.R., E.M.B.), Harborview Medical Center, Seattle, Washington; and Department of Surgery (J.C.), University of California San Francisco, San Francisco, California
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28
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Palanca M, Liebsch C, Hübner S, Marras D, Ruspi ML, Marconi F, Cristofolini L, Wilke HJ. Global and local characterization explains the different mechanisms of failure of the human ribs. J Mech Behav Biomed Mater 2021; 125:104931. [PMID: 34736031 DOI: 10.1016/j.jmbbm.2021.104931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/03/2021] [Accepted: 10/25/2021] [Indexed: 10/20/2022]
Abstract
Knowledge of the mechanics and mechanistic reasons inducing rib fracture is fundamental for forensic investigations and for the design of implants and cardiopulmonary resuscitation devices. A mechanical rationale to explain the different rib mechanisms of failure is still a challenge. The aim of this work was to experimentally characterize human ribs to test the hypothesis that a correlation exists between the ribs properties and the mechanism of failure. 89 ribs were tested in antero-posterior compression. The full-field strain distribution was measured through Digital Image Correlation. The fracture load ranged 7-132 N. Two main different mechanisms of failure were observed: brittle and buckling. The strain analysis showed that the direction of principal strains was either aligned with the ribs, or oblique, around 45°, with a rather uniform direction in the most strained area. The maximum principal strains were in the range between 1000 and 30000 microstrain and the minimum principal strain between -30000 and -800 microstrain. The ribs undergoing brittle fracture had significantly thicker cortical bone than those undergoing buckling. Also, larger tensile strains were observed in the specimens with brittle fracture than in the buckling ones. These findings support the focus of cortical thickness modelling which could help in sharpening computational models for the aforesaid purposes.
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Affiliation(s)
- Marco Palanca
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK; INSIGNEO Institute for in Silico Medicine, University of Sheffield, Sheffield, UK; Department of Industrial Engineering, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Christian Liebsch
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm ZTF, University Hospital Ulm, Ulm, Germany
| | - Shamila Hübner
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm ZTF, University Hospital Ulm, Ulm, Germany
| | - Daniele Marras
- Department of Industrial Engineering, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Maria Luisa Ruspi
- Department of Industrial Engineering, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Francesco Marconi
- Department of Industrial Engineering, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Luca Cristofolini
- Department of Industrial Engineering, Alma Mater Studiorum - Università di Bologna, Bologna, Italy.
| | - Hans-Joachim Wilke
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center Ulm ZTF, University Hospital Ulm, Ulm, Germany
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29
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Gluncic V, Bonasera L, Gonzalez S, Lukić IK, Candido K. Combination of the T7 Unilateral Erector Spinae Plane Block and T10 Bilateral Retrolaminar Blocks in a Patient with Multiple Rib Fractures on the Right and T10-12 Vertebral Compression Fractures: A Case Report. Local Reg Anesth 2021; 14:99-102. [PMID: 34163238 PMCID: PMC8214557 DOI: 10.2147/lra.s312881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/18/2021] [Indexed: 11/23/2022] Open
Abstract
Multiple vertebral compression and rib fractures in elderly patients with pre-existing chronic obstructive pulmonary disease is a common scenario associated with significant morbidity and mortality. Severe pain prevents normal ventilation and leads to atelectasis, consolidation, and pneumonia. Subsequently, these patients frequently develop respiratory failure and require intubation and critical care. Therefore, adequate analgesia is often a life-saving intervention. Anesthetic management of a 78-year-old kyphotic patient with T6, T7, and T9 rib fractures on the right and T10-12 vertebral compression fractures sustained in an accidental fall is presented. She had inadequate pain control and was unable to take a deep breath or cough. Her respiratory status was deteriorating, with tachypnea and worsening hypoxia, necessitating bi-level positive airway pressure (BiPAP) support. Since thoracic epidural analgesia was contraindicated owing to compressive vertebral fractures and to the pending respiratory failure, we opted for a unilateral erector spinae plane (ESP) block at the T7 level and bilateral retrolaminar (RL) blocks at the T10 level. Following the procedure, the pain was immediately relieved and the patient was able to take deep breaths. Shortly thereafter, her respiratory status improved, with the respiratory rate coming back close to the baseline. The patient was subsequently weaned from BiPAP support and discharged from the intensive care unit. While the combination of ESP and RL blocks is not routinely used in patients with multiple rib and vertebral compression fractures, our report indicates that it may be an excellent alternative for analgesia in situations where thoracic epidural and/or paravertebral blocks are contraindicated and when timely intervention could be potentially life-saving.
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Affiliation(s)
- Vicko Gluncic
- Department of Anesthesia, Advocate Illinois Masonic Medical Center, Chicago, IL, 60657, USA
| | - Lara Bonasera
- Department of Anesthesia, Advocate Illinois Masonic Medical Center, Chicago, IL, 60657, USA
| | - Sergio Gonzalez
- Department of Anesthesia, Advocate Illinois Masonic Medical Center, Chicago, IL, 60657, USA
| | | | - Kenneth Candido
- Department of Anesthesia, Advocate Illinois Masonic Medical Center, Chicago, IL, 60657, USA
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30
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Gongola A, Bradshaw JC, Jin J, Jensen HK, Bhavaraju A, Margolick J, Sexton KW, Robertson R, Kalkwarf KJ. Retrospective study on rib fractures: smoking and alcohol matter for mortality and complications. Trauma Surg Acute Care Open 2021; 6:e000732. [PMID: 34212116 PMCID: PMC8207992 DOI: 10.1136/tsaco-2021-000732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/23/2021] [Indexed: 11/17/2022] Open
Abstract
Background Rib fractures and substance use are both common in trauma patients, but there is little data on how smoking and alcohol use may be associated with outcomes in these patients. We assessed the association between smoking or alcohol use disorder (AUD) and outcomes in patients with rib fractures. Methods We used institutional databases to conduct a retrospective review of patients with rib fractures at the only American College of Surgeons-verified adult level 1 trauma center in a rural state between 2015 and 2019. The key exposure variables were smoking and AUD. The key outcome variables were mortality and pulmonary complications (pneumonia, adult respiratory distress syndrome, and pneumothorax). We used multivariable regression for analysis and directed acyclic graphs to identify variables for adjustment. Results We identified 1880 eligible patients with rib fractures, including 693 (37%) who were smokers and 204 (11%) who had AUD. Compared with non-smokers, smokers were younger, more often male, and had lower mortality rates. Regression showed that smokers had a lower likelihood of mortality (OR 0.48; 95% CI 0.27 to 0.87; p=014). Likelihood of pneumonia, ARDS, and pneumothorax was not different between smokers and non-smokers. Compared with patients without AUD, patients with AUD were older, more often male, and had higher likelihood of pneumonia and lower likelihood of pneumothorax. Regression showed that patients with AUD had higher likelihood of pneumonia (OR 1.82; 95% CI 1.24 to 2.68; p=0.002) and lower likelihood of pneumothorax (OR 0.51; 95% CI 0.33 to 0.75; p=0.002). Discussion In trauma patients with rib fractures treated at a level 1 trauma center over 5 years, smoking was associated with decreased risk of mortality. These findings have implications for risk stratification and clinical decision-making for patients with rib fractures. Level of evidence III
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Affiliation(s)
| | - Jace C Bradshaw
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jing Jin
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Hanna K Jensen
- Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Avi Bhavaraju
- Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Joseph Margolick
- Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kevin W Sexton
- Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Ronald Robertson
- Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kyle J Kalkwarf
- Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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31
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Abstract
A 44-year-old man presented to the emergency department with fever and right anterior chest pain. He reported a persistent cough and the development of sudden-onset right anterior chest pain after coughing. The inspiratory pain in the right lung was severe, and therefore deep breathing was impossible. Chest CT revealed a fracture in the right seventh rib with consolidation and pleural effusion. A pleural fluid culture test result was positive for methicillin-susceptible Staphylococcus aureus. He was diagnosed with empyema associated with a cough-induced rib fracture. Thoracic drainage tube placement and intravenous antibiotic therapy successfully ameliorated his condition. He was discharged on day 13 and switched to an 8-week course of oral antibiotic therapy. There was no clinical relapse at the 6-month follow-up.
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Affiliation(s)
- Satoshi Hayano
- Department of Internal Medicine, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Masayuki Kashima
- Department of Internal Medicine, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
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32
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Clare D, Zink KL. Geriatric Trauma. Emerg Med Clin North Am 2021; 39:257-271. [PMID: 33863458 DOI: 10.1016/j.emc.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Geriatric trauma patients will continue to increase in prevalence as the population ages, and many specific considerations need to be made to provide appropriate care to these patients. This article outlines common presentations of trauma in geriatric patients, with consideration to baseline physiologic function and patterns of injury that may be more prevalent in geriatric populations. Additionally, the article explores specific evidence-based management practices, the significance of trauma team and geriatrician involvement, and disposition decisions.
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Affiliation(s)
- Drew Clare
- Department of Emergency Medicine, University of Florida, 655 W 8th st, Jacksonville, FL 32209, USA.
| | - Korie L Zink
- Johns Hopkins University, 1830 E. Monument St, St 6-100, Baltimore, MD 21224, USA. https://twitter.com/koriezinkmd
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33
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Choi J, Mulaney B, Laohavinij W, Trimble R, Tennakoon L, Spain DA, Salomon JA, Goldhaber-Fiebert JD, Forrester JD. Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups. J Trauma Acute Care Surg 2021; 90:451-458. [PMID: 33559982 DOI: 10.1097/ta.0000000000003021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest. METHODS This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios. RESULTS Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest. CONCLUSIONS Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study. LEVEL OF EVIDENCE Economic/decision, level II.
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Affiliation(s)
- Jeff Choi
- From the Department of Surgery (J.C., L.T., D.A.S., J.D.F.), Division of General Surgery, Department of Epidemiology and Population Health (J.C.), Surgeons Writing About Trauma (J.C., B.M., R.T., L.T., D.A.S., J.D.F.), and School of Medicine (B.M., R.T.), Stanford University, Stanford, California; Department of Surgery, Chulalongkorn University (W.L.), Bangkok, Thailand; and Stanford Health Policy (J.A.S., J.D.G.-F.), Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
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34
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Mukerji S, Tan E, May C, Micanovic C, Blakemore P, Phelps K, Melville H, Jones P. Retrospective validation of a risk stratification tool developed for the management of patients with blunt chest trauma (the STUMBL score). Emerg Med Australas 2021; 33:841-847. [PMID: 33599054 DOI: 10.1111/1742-6723.13740] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/11/2021] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess validity of the STUMBL score in New Zealand for complications of blunt chest trauma without multi-trauma and immediate life-threatening injuries. METHODS A multi-centre, retrospective observational study was carried out in five EDs. Area under the receiver operating characteristic curve (AUROC) was calculated for all, early and late complications and ethnic sub-groups. Youden Index generated for each ROC was used to indicate cut scores for risks of complication, ICU admission, prolonged length of stay (LOS) and mortality. RESULTS A total of 445 patients were included. AUROC for all complications composite were (0.73, 95% confidence interval [CI] 0.68-0.77), mortality (0.92, 95% CI 0.89-0.94), ICU admissions (0.78, 95% CI 0.73-0.81) and prolonged LOS (0.80, 95% CI 0.76-0.83) were calculated. The score performed better in the New Zealand European (Pākehā) sub-group compared to Māori and Pasifika (AUROC [95% CI]: 0.80 [0.73-0.85], 0.69 [0.56-0.79], 0.66 [0.46-0.82], respectively). Patients with scores >12 were at risk of complications from blunt chest trauma, >15 at risk of prolonged LOS and >18 at risk of ICU admission and mortality. CONCLUSIONS The STUMBL score at a cut-off of <12 did not predict all complications sufficiently well to recommend for general use in our population. However, a score >15 predicted prolonged LOS and a score >18 predicted mortality sufficiently to be clinically useful for these outcomes. The score is more accurate in New Zealand Pākehā and needs to be used with caution in Māori and Pasifika populations. A larger prospective validation is required to further assess the score.
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Affiliation(s)
- Saptarshi Mukerji
- Emergency Department, Capital and Coast District Health Board, Wellington, New Zealand
| | - Eunicia Tan
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Emergency Department, Middlemore Hospital, Auckland, New Zealand
| | - Charlotte May
- Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | | | - Paul Blakemore
- Emergency Department, Tauranga Hospital, Bay of Plenty, New Zealand
| | - Kelly Phelps
- Emergency Department, Whakatane Hospital, Whakatane, New Zealand
| | - Hannah Melville
- Emergency Department, Capital and Coast District Health Board, Wellington, New Zealand
| | - Peter Jones
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Emergency Department, Auckland City Hospital, Auckland, New Zealand
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35
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Choi J, Mulaney B, Sun B, Trimble R, Tennakoon L, Spain DA, Forrester JD. Concomitant Sternal Fractures: Harbinger of Worse Pulmonary Complications and Mortality in Patients With Rib Fractures. Am Surg 2021; 88:1201-1206. [PMID: 33522281 DOI: 10.1177/0003134821991978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Sternal and rib fractures are common concomitant injuries. However, the impact of concurrent sternal fractures on clinical outcomes of patients with rib fractures is unclear. We aimed to unveil the pulmonary morbidity and mortality impact of concomitant sternal fractures among patients with rib fractures. METHODS We identified adult patients admitted with traumatic rib fractures with vs. without concomitant sternal fractures using the 2012-2014 National Inpatient Sample (NIS). After 2:1 propensity score matching and adjustment for residual imbalances, we compared risk of pulmonary morbidity and mortality between patients with vs. without concomitant sternal fractures. Subgroup analysis in patients with flail chest assessed whether sternal fractures modify the association between undergoing surgical stabilization of rib fractures (SSRF) and pulmonary morbidity or mortality. RESULTS Of 475 710 encounters of adults admitted with rib fractures, 24 594 (5%) had concomitant sternal fractures. After 2:1 propensity score matching, patients with concomitant sternal fractures had 70% higher risk (95% CI: 50-90% higher, P < 0.001) of undergoing tracheostomy, 40% higher risk (30-50% higher, P <.001) of undergoing intubation, and 20% higher risk of respiratory failure (10-30% higher, P <.001) and mortality (10-40% higher, P =.007). Subgroup analysis of 8600 patients with flail chest showed concomitant sternal fractures did not impact the association between undergoing SSRF and any pulmonary morbidity or mortality. CONCLUSION Concomitant sternal fractures are associated with increased risk for pulmonary morbidity and mortality among patients with rib fractures. However, our findings are limited by a binary definition of sternal fractures, which encompasses heterogeneous injury patterns with likely variable clinical relevance.
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Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.,Department of Epidemiology and Population Health, 6429Stanford University, CA, USA.,Surgeons Writing about Trauma, 6429Stanford University, CA, USA
| | - Bianca Mulaney
- Surgeons Writing about Trauma, 6429Stanford University, CA, USA.,School of Medicine, 6429Stanford University, CA, USA
| | - Beatrice Sun
- Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.,Surgeons Writing about Trauma, 6429Stanford University, CA, USA
| | - Richard Trimble
- Surgeons Writing about Trauma, 6429Stanford University, CA, USA.,School of Medicine, 6429Stanford University, CA, USA
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.,Surgeons Writing about Trauma, 6429Stanford University, CA, USA
| | - David A Spain
- Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.,Surgeons Writing about Trauma, 6429Stanford University, CA, USA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.,Surgeons Writing about Trauma, 6429Stanford University, CA, USA
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Abshagen KF, Stolberg-Stolberg J, Loyen JP, Riesenbeck O, Everding J, Freise H, Raschke MJ. [Improvement in breathing mechanics by plate osteosynthesis of the ribs after cardiac massage : Case report and review of the literature]. Unfallchirurg 2021; 124:774-778. [PMID: 33433646 PMCID: PMC8397626 DOI: 10.1007/s00113-020-00950-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 11/24/2022]
Abstract
Es wird der Fall eines 69-jährigen Patienten vorgestellt, welcher nach wiederholter Herzdruckmassage (CPR) multiple Rippenfrakturen und eine Sternumfraktur mit inverser Atmung zeigte. Aufgrund der insuffizienten Atemmechanik wurde am 10. Tag nach Reanimation die Indikation zur Plattenosteosynthese der Rippen gestellt. Der Patient konnte am 4. postoperativen Tag extubiert werden. Die Literatur zeigt 5 weitere Fälle. Während es über die Verletzungsmuster nach CPR zahlreiche internationale Arbeiten gibt, ist zur Behandlung des instabilen Thorax nach CPR keine Evidenz gegeben. Jedoch konnte die Osteosynthese von Rippenfrakturen bei traumatischer Genese Vorteile wie verringerte Intensivbehandlungszeit, geringere beatmungsassoziierte Pneumonien, weniger atemabhängige Schmerzen und geringere Kosten für das Gesundheitssystem zeigen. Bei der Behandlung von reanimierten Patienten sollte im interdisziplinären Konsens auch die Osteosynthese von Rippenfrakturen berücksichtigt werden.
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Affiliation(s)
- Karl Friedrich Abshagen
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Waldeyerstraße 1, 48149, Münster, Deutschland.
| | - Josef Stolberg-Stolberg
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Waldeyerstraße 1, 48149, Münster, Deutschland
| | - Jan Philipp Loyen
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Waldeyerstraße 1, 48149, Münster, Deutschland
| | - Oliver Riesenbeck
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Waldeyerstraße 1, 48149, Münster, Deutschland
| | - Jens Everding
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Waldeyerstraße 1, 48149, Münster, Deutschland
| | - Hendrik Freise
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Waldeyerstraße 1, 48149, Münster, Deutschland
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Choi J, Zamary K, Barreto NB, Tennakoon L, Davis KM, Trickey AW, Spain DA. Intravenous lidocaine as a non-opioid adjunct analgesic for traumatic rib fractures. PLoS One 2020; 15:e0239896. [PMID: 32986770 PMCID: PMC7521689 DOI: 10.1371/journal.pone.0239896] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 09/01/2020] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Pain management is the pillar of caring for patients with traumatic rib fractures. Intravenous lidocaine (IVL) is a well-established non-opioid analgesic for post-operative pain, yet its efficacy has yet to be investigated in trauma patients. We hypothesized that IVL is associated with decreased inpatient opioid requirements among patients with rib fractures. METHODS We retrospectively evaluated adult patients presenting to our Level 1 trauma center with isolated chest wall injuries. After 1:1 propensity score matching patients who received vs did not receive IVL, we compared the two groups' average daily opioid use, opioid use in the last 24 hours of admission, and pain scores during admissions hours 24-48. We performed multivariable linear regression for these outcomes (with sensitivity analysis for the opioid use outcomes), adjusting for age as a moderating factor and controlling for hospital length of stay and injury severity. RESULTS We identified 534 patients, among whom 226 received IVL. Those who received IVL were older and had more serious injury. Compared to propensity-score matched patients who did not receive IVL, patients who received IVL had similar average daily opioid use and pain scores, but 40% lower opioid use during the last 24 hours of admission (p = 0.002). Multivariable regression-with and without sensitivity analysis-did not show an effect of IVL on any outcomes. CONCLUSION IVL was crudely associated with decreased opioid requirements in the last 24 hours of admission, the time period associated with opioid use at 90 days post-discharge. However, we did not observe beneficial effects of IVL on multivariable adjusted analyses; we are conducting a randomized control trial to further evaluate IVL's opioid-sparing effects for patients with rib fractures.
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Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA, United States of America
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, United States of America
- * E-mail:
| | - Kirellos Zamary
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA, United States of America
- Department of Surgery, St. Joseph Health Medical Group, Santa Rosa, CA, United States of America
| | - Nicolas B. Barreto
- Stanford-Surgery Policy Improvement Research & Education Center, Department of Surgery, Stanford University, Stanford, CA, United States of America
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA, United States of America
| | - Kristen M. Davis
- Stanford-Surgery Policy Improvement Research & Education Center, Department of Surgery, Stanford University, Stanford, CA, United States of America
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research & Education Center, Department of Surgery, Stanford University, Stanford, CA, United States of America
| | - David A. Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA, United States of America
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Bachoumas K, Levrat A, Le Thuaut A, Rouleau S, Groyer S, Dupont H, Rooze P, Eisenmann N, Trampont T, Bohé J, Rieu B, Chakarian JC, Godard A, Frederici L, Gélinotte S, Joret A, Roques P, Painvin B, Leroy C, Benedit M, Dopeux L, Soum E, Botoc V, Fartoukh M, Hausermann MH, Kamel T, Morin J, De Varax R, Plantefève G, Herbland A, Jabaudon M, Duburcq T, Simon C, Chabanne R, Schneider F, Ganster F, Bruel C, Laggoune AS, Bregeaud D, Souweine B, Reignier J, Lascarrou JB. Epidural analgesia in ICU chest trauma patients with fractured ribs: retrospective study of pain control and intubation requirements. Ann Intensive Care 2020; 10:116. [PMID: 32852675 PMCID: PMC7450151 DOI: 10.1186/s13613-020-00733-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/17/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Nonintubated chest trauma patients with fractured ribs admitted to the intensive care unit (ICU) are at risk for complications and may require invasive ventilation at some point. Effective pain control is essential. We assessed whether epidural analgesia (EA) in patients with fractured ribs who were not intubated at ICU admission decreased the need for invasive mechanical ventilation (IMV). We also looked for risk factors for IMV. STUDY DESIGN AND METHODS This retrospective, observational, multicenter study conducted in 40 ICUs in France included consecutive patients with three or more fractured ribs who were not intubated at admission between July 2013 and July 2015. RESULTS Of the 974 study patients, 788 were included in the analysis of intubation predictors. EA was used in 130 (16.5%) patients, and 65 (8.2%) patients required IMV. Factors independently associated with IMV were chronic respiratory disease (P = 0.008), worse SAPS II (P < 0.0001), flail chest (P = 0.02), worse Injury Severity Score (P = 0.0003), higher respiratory rate at admission (P = 0.02), alcohol withdrawal syndrome (P < 0.001), and noninvasive ventilation (P = 0.04). EA was not associated with decreases in IMV requirements, median numerical rating scale pain score, or intravenous morphine requirements from day 1 to day 7. CONCLUSIONS EA was not associated with a lower risk of IMV in chest trauma patients with at least 3 fractured ribs, moderate pain, and no intubation on admission. Further studies are needed to clarify the optimal pain control strategy in chest trauma patients admitted to the ICU, notably those with severe pain or high opioid requirements.
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Affiliation(s)
| | - Albrice Levrat
- Intensive Care Unit, Regional Hospital Center, Annecy, France
| | - Aurélie Le Thuaut
- Plateforme de la méthodologie et de la Biostatistique, Direction de la Recherche Clinique, CHU de Nantes, 44093, Nantes Cedex, France
| | | | - Samuel Groyer
- Intensive Care Unit, Hospital Center, Montauban, France
| | - Hervé Dupont
- Surgical Intensive Care Unit, University Hospital, Amiens, France
| | - Paul Rooze
- Surgical Intensive Care Unit, University Hospital, Nantes, France
| | | | | | | | - Benjamin Rieu
- Surgical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | | | - Aurélie Godard
- Intensive Care Unit, Regional Hospital Center, Saint-Brieuc, France
| | - Laura Frederici
- Intensive Care Unit, Regional Hospital Center, Sud Francilien, Corbeil-Essone, France
| | | | - Aurélie Joret
- Surgical Intensive Care Unit, University Hospital, Caen, France
| | - Pascale Roques
- Intensive Care Unit, Regional Hospital Center, Cherbourg, France
| | - Benoit Painvin
- Intensive Care Unit, Regional Hospital Center, Lorient, France
| | - Christophe Leroy
- Intensive Care Unit, Regional Hospital Center, Puy en Velay, France
| | - Marcel Benedit
- Intensive Care Unit, Regional Hospital Center, Moulins, France
| | - Loic Dopeux
- Intensive Care Unit, Regional Hospital Center, Vichy, France
| | - Edouard Soum
- Intensive Care Unit, Regional Hospital Center, Périgueux, France
| | - Vlad Botoc
- Intensive Care Unit, Regional Hospital Center, Saint-Malo, France
| | - Muriel Fartoukh
- Intensive Care Unit, University Hospital, Tenon, Paris, France
| | | | - Toufik Kamel
- Intensive Care Unit, Regional Hospital Center, Orléans, France
| | - Jean Morin
- Respiratory Care Unit, University Hospital, Nantes, France
| | - Roland De Varax
- Intensive Care Unit, Regional Hospital Center, Macon, France
| | | | | | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand and GReD, CNRS, UMR 6293, INSERM U1103, Universite Clermont Auvergne, Clermont-Ferrand, France
| | | | - Christelle Simon
- Intensive Care Unit, Regional Hospital Center, Versailles, France
| | - Russell Chabanne
- Neurological Intensive Care Unit, University Hospital, Clermont-Ferrand, France
| | - Francis Schneider
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Cedric Bruel
- Intensive Care Unit, Saint-Joseph Hospital Center, Paris, France
| | | | | | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Jean Reignier
- Médecine Intensive Réanimation, University Hospital, Nantes, France
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Bankhead-Kendall B, Radpour S, Luftman K, Guerra E, Ali S, Getto C, Brown CV. Rib Fractures and Mortality: Breaking the Causal Relationship. Am Surg 2020. [DOI: 10.1177/000313481908501127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rib fractures have long been considered as a major contributor to mortality in the blunt trauma patient. We hypothesized that rib fractures can be an excellent predictor of mortality, but rarely contribute to cause death. We performed a retrospective study (2008–2015) of blunt trauma patients admitted to our urban, Level I trauma center with one or more rib fractures. Medical records were reviewed in detail. Rib fracture deaths were those from any respiratory sequelae or hemorrhage from rib fractures. There were 4413 blunt trauma patients who sustained one or more rib fractures and 295 (6.8%) died. Rib fracture patients who died had a mean Injury Severity Score = 38 and chest Abbreviated Injury Score = 3.4. Rib fractures were the cause of death in only 21 patients (0.5%). After excluding patients who were dead on arrival, patients dying as a result of their rib fractures were found to be older ( P < 0.0001) and had a higher admission respiratory rate ( P = 0.02). Multivariable logistic regression found that age ≥65 was the only variable independently associated with mortality directly related to rib fractures (odds ratio 4.1, 95% confidence interval = 1.3–13.3, P value < .0001). Mortality in patients with rib fractures is uncommon (7%), and mortality directly related to rib fractures is rare (0.5%). Older patients are four times more likely to die as a direct result of rib fractures and may require additional resources to avoid mortality.
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Affiliation(s)
- Brittany Bankhead-Kendall
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
- Trauma Services, Dell Seton Medical Center at the University of Texas at Austin, Austin, Texas; and
| | - Sepeadeh Radpour
- Trauma Services, Dell Seton Medical Center at the University of Texas at Austin, Austin, Texas; and
| | - Kevin Luftman
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
- Trauma Services, Dell Seton Medical Center at the University of Texas at Austin, Austin, Texas; and
| | - Erin Guerra
- Trauma Services, Dell Seton Medical Center at the University of Texas at Austin, Austin, Texas; and
| | - Sadia Ali
- Trauma Services, Dell Seton Medical Center at the University of Texas at Austin, Austin, Texas; and
| | - Christopher Getto
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
- Anesthesiology, Dell Seton Medical Center at the University of Texas at Austin, Austin, Texas
| | - Carlos V.R. Brown
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
- Trauma Services, Dell Seton Medical Center at the University of Texas at Austin, Austin, Texas; and
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Whitson BA, McGonigal MD, Anderson CP, Dries DJ. Increasing Numbers of Rib Fractures Do Not Worsen Outcome: An Analysis of the National Trauma Data Bank. Am Surg 2020. [DOI: 10.1177/000313481307900224] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Increasing age and number of rib fractures are thought to portend a worse outcome with blunt chest trauma, although this is not clearly substantiated in the literature. We hypothesized that these parameters have a significant and synergistic effect, worsening patient outcome. Using the National Trauma Data Bank, we evaluated patients from 2002 to 2006. Patients with a rib fracture International Classification of Diseases, 9th Revision code were included; those with sternal fractures were excluded. Data on demographics, injury, comorbidity, complications, intensive care unit duration, ventilator duration, length of stay, and death were collected. Significant univariate predictors were included in the multivariate logistic regression analysis to adjust for any potential confounders. We identified 35,467 patients who met the inclusion. The mean age was 45.5 years with a mean Injury Severity Score of 19.3. There were 2.1 per cent open rib fractures. Using univariate analysis, rib fracture number was significant. However, once multivariate analyses were applied, the number of rib fractures was not found to be an independent predictor of outcome. The number of rib fractures is not an independent predictor of outcome. Age and overall trauma burden are more powerful predictors of poor outcomes. Treatment focus should shift from the chest to the broader scope of injuries and comorbidities.
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Affiliation(s)
- Bryan A. Whitson
- Department of Surgery, University of Minnesota, St. Paul, Minnesota; and
| | - Michael D. McGonigal
- Department of Surgery, University of Minnesota, St. Paul, Minnesota; and
- Regions Hospital, HealthPartners, St. Paul, Minnesota
| | | | - David J. Dries
- Department of Surgery, University of Minnesota, St. Paul, Minnesota; and
- Regions Hospital, HealthPartners, St. Paul, Minnesota
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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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The Sequential Clinical Assessment of Respiratory Function (SCARF) score: A dynamic pulmonary physiologic score that predicts adverse outcomes in critically ill rib fracture patients. J Trauma Acute Care Surg 2020; 87:1260-1268. [PMID: 31425473 DOI: 10.1097/ta.0000000000002480] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rib fracture scoring systems are limited by a lack of serial pulmonary physiologic variables. We created the Sequential Clinical Assessment of Respiratory Function (SCARF) score and hypothesized that admission, maximum, and rising scores predict adverse outcomes among critically ill rib fracture patients. METHODS Prospective cohort study of rib fracture patients admitted to the surgical intensive care unit (ICU) at a Level I trauma center from August 2017 to June 2018. The SCARF score was developed a priori and validated using the cohort. One point was assigned for: <50% predicted, respiratory rate >20, numeric pain score ≥5, and inadequate cough. Demographics, injury patterns, analgesics, and adverse pulmonary outcomes were abstracted. Performance characteristics of the score were assessed using the receiver operator curve area under the curve. RESULTS Three hundred forty scores were available from 100 patients. Median admission and maximum SCARF score was 2 (range 0-4). Likelihood of pneumonia (p = 0.04), high oxygen requirement (p < 0.01), and prolonged ICU length of stay (p < 0.01) were significantly associated with admission and maximum scores. The receiver operator curve area under the curve for the maximum SCARF score for these outcomes were 0.86, 0.76, and 0.79, respectively. In 10 patients, the SCARF score worsened from admission to day 2; these patients demonstrated increased likelihood of pneumonia (p = 0.04) and prolonged ICU length of stay (p = 0.07). Patients who developed complications maintained a SCARF score one point higher throughout ICU stay compared with patients who did not (p = 0.04). The SCARF score was significantly associated with both narcotic (p = 0.03) and locoregional anesthesia (p = 0.03) usage. CONCLUSION Admission, maximum, daily, and rising scores were associated with utilization of pain control therapies and development of adverse outcomes. The SCARF score may be used to guide therapies for critically ill rib fracture patients, with a proposed threshold greater than 2. LEVEL OF EVIDENCE Prognostic study, level II.
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Abstract
BACKGROUND There remains a lack of knowledge about readmission characteristics after sustaining rib fractures. We aimed to determine rates, characteristics, and predictive/protective factors associated with unexpected reevaluation and readmission after rib cage injury. METHODS A retrospective review was performed based on trauma patients evaluated at an urban Level I trauma center from January 2014 to December 2016. Adult patients sustaining blunt trauma with more than one rib fracture or a sternomanubrial fracture were defined as having moderate to severe rib cage injury. Exclusion criteria included penetrating injury, death during initial hospitalization, and only one rib fracture. Reevaluation was defined as presenting at a hospital within 90 days of discharge urgently or emergently. Demographics, injury characteristics, comorbidities, complications, imaging, and readmission data were collected. Univariate and multivariate analysis was performed with a significance of p less than 0.05. RESULTS During the study period, 11,667 patients underwent trauma evaluation, of which 1,717 patients were found to have a moderate to severe rib cage injury. Within 90 days, 397 (23.1%) of patients underwent reevaluation, while 177 (10.3%) required readmission. One hundred forty-two (8.3%) patients were reevaluated specifically for chest-related complaints, and 55 (3.2%) required readmission. On univariate analysis, Injury Severity Score greater than 15, hospital length of stay longer than 7 days, intensive care unit (ICU) length of stay longer than 3 days, a worsened chest x-ray at discharge, a psychiatric comorbidity, a smoking comorbidity, deep vein thrombosis, unplanned readmission to the ICU, and unplanned intubation were higher in the overall reevaluation cohort. On multivariate analysis, age of 15 years to 35 years, Risk Assessment Profile score greater than 8, hypertension, psychiatric comorbidity, current smoker, and unplanned return to the ICU on index admission were predictive of reevaluation of overall reevaluation. CONCLUSION Moderate to severe rib cage injury is associated with high rates of reevaluation and readmission. Younger patients who smoke and required a return to the ICU are at greater risk for readmission. LEVEL OF EVIDENCE Level IV, Prognostic and Epidemiologic.
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Ketamine infusion for pain control in adult patients with multiple rib fractures: Results of a randomized control trial. J Trauma Acute Care Surg 2020; 86:181-188. [PMID: 30376537 DOI: 10.1097/ta.0000000000002103] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rib fractures occur in up to 40% of trauma patients and are associated with increased mortality. Opiate-based pain regimens remain the cornerstone of rib fracture management; however, concerns around opioids have fostered interest in alternative analgesics. Ketamine is currently being used in lieu of opioids, but little evidence exists supporting its use within the trauma population. METHODS A prospective, randomized, double-blind placebo-controlled trial of adult patients with three or more rib fractures admitted to a Level I trauma center was conducted. Exclusion criteria included age older than 64 years, Glasgow Coma Scale score less than 13, and chronic opiate use. The experimental arm received low-dose ketamine (LDK) at 2.5 μg·kg·min while the placebo cohort received an equivalent rate of 0.9% normal saline. All infusions were continued for 48 hours. The primary outcome was reduction in numeric pain score (NPS) during the first 24 hours. Secondary outcomes studied included oral morphine equivalent (OME) utilization, length of stay, epidural rates, pulmonary complications, and adverse events. RESULTS Forty-five (49%) of 91 patients were randomized to the experimental arm. Both groups were similar in makeup. Overall, 74.7% were male, had a median age of 49 years, and an Injury Severity Score (ISS) of 14. Low-dose ketamine was not associated with a significant reduction in 24-hour NPS or OME totals. Subgroup analysis of 45 severely injured patients (ISS, >15) demonstrated that LDK was associated with a significant reduction in OME utilization during the first 24 hours (35.7 vs. 68, p = 0.03), 24 hours to 48 hours (64.2 vs. 96, p = 0.03), and overall (152.1 vs. 198, p = 0.048). No difference in other secondary outcomes or adverse events was noted. CONCLUSION Low-dose ketamine failed to decrease NPS or OME within the overall cohort, but a decrease in OME was observed among patients with an ISS greater than 15. Confirmatory studies are necessary to determine if LDK is a useful adjunct among severely injured patients. LEVEL OF EVIDENCE Therapeutic study, level II.
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Ketamine infusion for pain control in elderly patients with multiple rib fractures: Results of a randomized controlled trial. J Trauma Acute Care Surg 2020; 87:1181-1188. [PMID: 31425468 DOI: 10.1097/ta.0000000000002479] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rib fractures are associated with increased mortality, particularly in the elderly. While opiate-based pain regimens remain the cornerstone of rib fracture management, issues related to opioids have driven research into alternative analgesics. Adjunctive ketamine use in lieu of opioids continues to increase but little evidence exists to support its efficacy or safety within the elderly trauma population. METHODS A prospective, randomized, double-blind placebo-controlled trial of elderly patients (age, ≥65 years) with three or more rib fractures admitted to a Level I trauma center was conducted. Exclusion criteria included Glasgow Coma Scale score less than 14, and chronic opiate use. Groups were randomized to either low-dose ketamine (LDK) at 2 μg·kg·min or an equivalent rate of 0.9% normal saline. The primary outcome was reduction in numeric pain scores (NPS). Secondary outcomes included oral morphine equivalent (OME) utilization, epidural rates, pulmonary complications, and adverse events. RESULTS Thirty (50.8%) of 59 were randomized to the experimental arm. Groups were similar in makeup. Low-dose ketamine failed to reduce 24-hour NPS or OME totals. Subgroup analysis of 24 patients with Injury Severity Score greater than 15 demonstrated that LDK was associated with a reduction in OME utilization the first 24-hours (25.6 mg vs. 42.6 mg, p = 0.04) but at no other time points. No difference in other secondary outcomes or adverse events was noted. CONCLUSION Low-dose ketamine failed to affect NPS or OME within the overall cohort, but a decrease in OME was observed in those with an Injury Severity Score greater than 15. Additional studies are necessary to confirm whether LDK benefits severely injured elderly patients. LEVEL OF EVIDENCE Therapeutic, level I.
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Opioid prescription practices for patients discharged from the emergency department with acute musculoskeletal fractures. CAN J EMERG MED 2020; 22:486-493. [PMID: 32436484 DOI: 10.1017/cem.2020.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Opioid related mortality rate has increased 200% over the past decade. Studies show variable emergency department (ED) opioid prescription practices and a correlation with increased long-term use. ED physicians may be contributing to this problem. Our objective was to analyze ED opioid prescription practices for patients with acute fractures. METHODS We conducted a review of ED patients seen at two campuses of a tertiary care hospital. We evaluated a consecutive sample of patients with acute fractures (January 2016-April 2016) seen by ED physicians. Patients admitted or discharged by consultant services were excluded. The primary outcome was the proportion of patients discharged with an opioid prescription. Data were collected using screening lists, electronic records, and interobserver agreement. We calculated simple descriptive statistics and a multivariable analysis. RESULTS We enrolled 816 patients, including 441 females (54.0%). Most common fracture was wrist/hand (35.2%). 260 patients (31.8%) were discharged with an opioid; hydromorphone (N = 115, range 1-120 mg) was most common. 35 patients (4.3%) had pain related ED visits <1 month after discharge. Fractures of the lumbar spine (OR 10.78 [95% CI: 3.15-36.90]) and rib(s)/sternum/thoracic spine (OR 5.46 [95% CI: 2.88-10.35)] had a significantly higher likelihood of opioid prescriptions. CONCLUSIONS The majority of patients presenting to the ED with acute fractures were not discharged with an opioid. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Overall, there were few return to ED visits. We recommend standardization of ED opioid prescribing, with attention to limiting total dosage.
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Liu R, Clark L, Bautista A. Unilateral Bilevel Erector Spinae Plane Catheters for Flail Chest: A Case Report. A A Pract 2020; 14:e01211. [DOI: 10.1213/xaa.0000000000001211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Rib fractures are a common reason for hospital admission and are associated with significant morbidity and mortality. This article discusses the management of simple rib fractures and provides practical guidance for junior doctors involved in the care of these patients. Careful assessment to identify patients at high risk of complications is essential and calculation of a rib fracture score can aid management decisions. Pain from rib fractures can be severe and requires multimodal analgesia started promptly and proactively on hospital admission. This may include the use of regional anaesthetic techniques such as thoracic epidurals and erector spinae blocks for patients with significant chest trauma or those at high risk of pulmonary complications.
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Affiliation(s)
- Zachary Jeffery
- Specialty Training Registrar in Anaesthesia, Department of Anaesthetics, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton TA1 5DA
| | - Matthew Everson
- Specialty Training Registrar in Anaesthesia, Department of Anaesthetics, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton TA1 5DA
| | - Suzanne Carty
- Consultant in Anaesthesia and Pain Medicine, Department of Anaesthetics, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton
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Risk factors for pneumonia following rib fractures. Am J Emerg Med 2020; 38:610-612. [DOI: 10.1016/j.ajem.2019.10.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/10/2019] [Accepted: 10/17/2019] [Indexed: 11/22/2022] Open
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50
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Hsieh CH, Tsai PL, Huang CY, Chuang JF, Chou SE, Su WT, Hsu SY. Factors affecting mortality in trauma patients with more than three rib fractures. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_24_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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