Magnitude of rib fracture displacement predicts opioid requirements

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Abstract

<div class="section"> <a class="named-anchor" id="S1">  </a> <h5 class="section-title" id="d4985602e164">Introduction</h5> <p id="P1">It is unknown whether the magnitude of rib fracture (RF) displacement predicts pain medication requirements in blunt chest trauma patients. </p> </div><div class="section"> <a class="named-anchor" id="S2">  </a> <h5 class="section-title" id="d4985602e169">Methods</h5> <p id="P2">Adult blunt RF patients undergoing chest computed tomography (CT) admitted to an urban Level 1 trauma center (2007–2012) were retrospectively reviewed. Pain management in those with displaced RF (DRF), non-displaced RF (NDRF), or combined DRF and NDRF (CRF) was compared by univariate analysis. Linear regression models were developed to determine whether total opioids requirements [expressed as log morphine equianalgesic dose (MED)] could be predicted by the magnitude of RF displacement (expressed as the sum of the Euclidean distance of all displaced RF) or number of RF, after adjusting for patient and injury characteristics. </p> </div><div class="section"> <a class="named-anchor" id="S3">  </a> <h5 class="section-title" id="d4985602e174">Results</h5> <p id="P3">There were 245 patients, of whom 39 (16%) had DRF only, 77 (31%) had NDRF only, and 129 (53%) had CRF. Opioids were given to 224 (91%) patients. Compared to DRF (mean1.7 RF/patient) and NDRF patients (2.4 RF/patient), those with CRF (6.8 RF/patient) were older and had more RF per patient and a higher ISS and MED (251 vs. 53 and 105 mg, respectively, p<0.0001 and p=0.0045). They also more frequently received patient controlled analgesia. DRF patients had a lower mean ISS and MED and received more epidural analgesia compared with patients with NDRF. Total MED was associated with both the magnitude of RF displacement (p<0.0001) and the number of RF (p<0.0001). Every 5 mm increase in total displacement predicted a 6.3% increase in mean MED (p=0.0035) while every additional RF predicted an 11.2% increase in MED (p=0.0001). These associations included adjustment for age, ISS, and presence of chest tubes. </p> </div><div class="section"> <a class="named-anchor" id="S4">  </a> <h5 class="section-title" id="d4985602e179">Conclusion</h5> <p id="P4">The magnitude of RF displacement and the number of RF predicted opioids requirements. This information may assist in anticipating patients with blunt RF who might have higher analgesic requirements. </p> </div><div class="section"> <a class="named-anchor" id="S5">  </a> <h5 class="section-title" id="d4985602e184">Level of Evidence</h5> <p id="P5">Prognostic study, level III.</p> </div>

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Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis.

C Battle, Jason Evans, Hayley Hutchings (2011)

The risk factors for mortality following blunt chest wall trauma have neither been well established or summarised. To summarise the risk factors for mortality in blunt chest wall trauma patients based on available evidence in the literature. A systematic review of English and non-English articles using MEDLINE, EMBASE and the Cochrane Library from their introduction until May 2010. Additional studies were identified by hand-searching bibliographies and contacting relevant clinical experts. Grey literature was sought by searching abstracts from all Emergency Medicine conferences. Broad search terms and inclusion criteria were used to reduce the number of missed studies. A two step study selection process was used. All published and unpublished observational studies were included if they investigated estimates of association between a risk factor and mortality for blunt chest wall trauma patients. A two step data extraction process using pre-defined data fields, including study quality indicators. Each study was appraised using a previously designed quality assessment tool and the STROBE checklist. Where sufficient data were available, odds ratios with 95% confidence intervals were calculated using Mantel-Haenszel method for the risk factors investigated. The I(2) statistic was calculated for combined studies in order to assess heterogeneity. Age, number of rib fractures, presence of pre-existing disease and pneumonia were found to be related to mortality in 29 identified studies. Combined odds ratio of 1.98 (1.86-2.11, 95% CI), 2.02 (1.89-2.15, 95% CI), 2.43 (1.03-5.72, 95% CI) and 5.24 (3.51-7.82) for mortality were calculated for blunt chest wall trauma patients aged 65 years or more, with three or more rib fractures, pre-existing conditions and pneumonia respectively. The risk factors for mortality in patients sustaining blunt chest wall trauma were a patient age of 65 years or more, three or more rib fractures and the presence of pre-existing disease especially cardiopulmonary disease. The development of pneumonia post injury was also a significant risk factor for mortality. As a result of the variable quality in the studies, the results of the selected studies should be interpreted with caution. Copyright © 2011 Elsevier Ltd. All rights reserved.

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Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery

Annalise Unsworth, M Kate Curtis, Stephen Edward Asha (2015)

Blunt chest trauma is associated with a high risk of morbidity and mortality. Complications in blunt chest trauma develop secondary to rib fractures as a consequence of pain and inadequate ventilation. This literature review aimed to examine clinical interventions in rib fractures and their impact on patient and hospital outcomes. A systematic search strategy, using a structured clinical question and defined search terms, was performed in MEDLINE, EMBASE, CINAHL and the Cochrane Library. The search was limited to studies of adult humans from 1990-March 2014 and yielded 977 articles, which were screened against inclusion/exclusion criteria. A hand search was then performed of the articles that met the eligibility criteria, 40 articles were included in this review. Each article was assessed using a quantitative critiquing guideline. From these articles, interventions were categorised into four main groups: analgesia, surgical fixation, clinical protocols and other interventions. Surgical fixation was effective in patients with flail chest at improving patient outcomes. Epidural analgesia, compared to both patient controlled analgesia and intravenous narcotics in patients with three or more rib fractures improved both hospital and patient outcomes, including pain relief and pulmonary function. Clinical pathways improve outcomes in patients ≥ 65 with rib fractures. The majority of reviewed papers recommended a multi-disciplinary approach including allied health (chest physiotherapy and nutritionist input), nursing, medical (analgesic review) and surgical intervention (stabilisation of flail chest). However there was a paucity of evidence describing methods to implement and evaluate such multidisciplinary interventions. Isolated interventions can be effective in improving patient and health service outcomes for patients with blunt chest injuries, however the literature recommends implementing strategies such as clinical pathways to improve the care and outcomes of thesetre patients. The implementation of evidence-practice interventions in this area is scarce, and evaluation of interventions scarcer still. Electronic supplementary material The online version of this article (doi:10.1186/s13049-015-0091-5) contains supplementary material, which is available to authorized users.

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Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair.

Linda J Mayberry, R. Mullins, Amy-Joan Ham … (2009)

Rib and sternal fracture repair are controversial. The opinion of surgeons regarding those patients who would benefit from repair is unknown. Members of the Eastern Association for the Surgery of Trauma, the Orthopedic Trauma Association, and thoracic surgeons (THS) affiliated with teaching hospitals in the United States were recruited to complete an electronic survey regarding rib and sternal fracture repair. Two hundred thirty-eight trauma surgeons (TRS), 97 orthopedic trauma surgeons (OTS), and 70 THS completed the survey. Eighty-two percent of TRS, 66% of OTS, and 71% of THS thought that rib fracture repair was indicated in selected patients. A greater proportion of surgeons thought that sternal fracture repair was indicated in selected patients (89% of TRS, 85% of OTS, and 95% of THS). Chest wall defect/pulmonary hernia (58%) and sternal fracture nonunion (>6 weeks) (68%) were the only two indications accepted by a majority of respondents. Twenty-six percent of surgeons reported that they had performed or assisted on a chest wall fracture repair, whereas 22% of surgeons were familiar with published randomized trials of the surgical repair of flail chest. Of surgeons who thought rib fracture or sternal fracture repair was rarely, if ever, indicated, 91% and 95%, respectively, specified that a randomized trial confirming efficacy would be necessary to change their negative opinion. A majority of surveyed surgeons reported that rib and sternal fracture repair is indicated in selected patients; however, a much smaller proportion indicated that they had performed the procedures. The published literature on surgical repair is sparse and unfamiliar to most surgeons. Barriers to surgical repair of rib and sternal fracture include a lack of expertise among TRS, lack of research of optimal techniques, and a dearth of randomized trials.