Blunt Chest Wall Trauma Research Articles

Aortic Laceration from Posterior Rib Fractures After a Ground-Level Fall: A Case Report

BackgroundRib fractures represent a common injury after blunt chest wall trauma with known complications including pneumothorax, hemothorax, pulmonary contusion, and pneumonia. This case report describes an emergency department patient with acute decompensation from aortic laceration as a rare complication of rib fractures. There are rare documented cases of this complication occurring in admitted patients with rib fractures but this is one of the only cases which describes this complication occurring in a patient presenting to the emergency department. Case ReportThis case describes a patient who was found down at her home presenting to the emergency department in acute distress. She was found to have three left-sided posterior rib fractures which had lacerated her thoracic aorta causing a large left hemothorax and acute decompensation. The patient was resuscitated in the emergency department followed by thoracic endovascular aortic repair in the operating room. The patient did well after surgical repair and was discharged from the hospital at her baseline mental and functional status.Why should an emergency physician be aware of this?It remains important to resuscitate an acutely ill patient based on history, physical exam, and vital signs. The key takeaway from this case report is that, although rare, aortic laceration remains a possible complication of posterior rib fractures in a patient who acutely decompensates

Analgesia for rib fractures: a narrative review.

Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach. Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts. Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities. Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

Diagnosis of Rib Fracture and Related Complications in Patients with Blunt Chest Wall Trauma Using Point-of-Care Ultrasound vs. Computed Tomography Scan

Background: One of the most common reasons for the referrals of patients to the trauma center is blunt chest injury. Objectives: To determine and compare the diagnostic value of point-of-care ultrasound (POCUS) and computed tomography (CT) scans in detecting rib fractures and their complications in patients with blunt chest wall trauma. Methods: The current cross-sectional study (October 2017-March 2018) was conducted in Shahid Rajaei Hospital, Shiraz, southern Iran. Convenient non-random sampling was employed. Patients with stable vital signs underwent ultra-sonography and later were evaluated by CT scan for fractures and related complications. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPP), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and accuracy were calculated and compared between the two procedures. Results: A total of 113 patients with a mean ± standard deviation (SD) age of 44.07 ± 20.07 years were enrolled, of whom 75 (66.3%) and 62 (54.9%) patients had at least one broken rib based on CT scan and sonography, respectively. The frequency of double fractures was higher than other conditions in both CT scans and ultrasound (35.53% and 37.10%). The overall sensitivity of ultrasound was calculated to be 81.58%, and with an increasing number of broken ribs, the sensitivity of ultrasound also increased (73.08% for identifying patients with one damaged rib versus 100% for detecting patients with five or more broken ribs). None of the 13 definite cases of pneumothorax were detected on ultrasound, while the sensitivity of ultrasound was appropriate for hemothorax and subperiosteal hematoma (85.71% and 80.23%, respectively). Conclusions: Ultrasound offers high sensitivity, specificity, and diagnostic power in diagnosing fractures and their complications, but considering the setting of our study, care should be taken when generalizing the findings of this study.

FTP1.1 Using the STUMBL score to assess blunt chest wall trauma - does improving accuracy lead to improved patient care?

Abstract The STUMBL score is widely used to assess risk of complications in patients with blunt chest wall trauma. We audited its use in guiding the management of patients with rib fractures at a London major trauma centre. Methods This was a closed-loop audit. Data were collected retrospectively from electronic patient records for a period of one month (October 2021). Results were disseminated at the Regional Major Trauma Network Governance meeting. Educational updates were provided for the multidisciplinary team. After this intervention, a second one month audit cycle was completed (December 2021). Results Thirty-nine patients were included in cycle 1, of whom 41% (n=16) had care stratified using the STUMBL score. Calculation accuracy was poor: 0% had a correct score and 56.3% (n=9) had a score calculated within ±3 of the correct figure. Post-intervention, there was a significant improvement in STUMBL use in the 34 patients assessed in cycle 2: 85.3% (n=29; p=0.0001) had a documented score. Accuracy also improved, with 44.8% (n=13) within ±3 of correct and 31.0% (n=9) correct. There was no significant difference in the proportion of patients who were treated according to guidelines (74.3% vs 53.8%) or who were under-treated (23.1% vs. 38.2%) following our intervention (p=0.18). Conclusions We found a number of barriers to implementing the STUMBL score. Its use and calculation accuracy was improved by education, but this did not result in more patients following the suggested treatment pathway. Further evaluation is required to understand this discrepancy.

Timing of regional analgesia in elderly patients with blunt chest-wall injury

BackgroundRib fractures represent a typical injury pattern in older people and are associated with respiratory morbidity and mortality. Regional analgesia modalities are adjuncts for pain management, but the optimal timing for their initiation remains understudied. We hypothesized that early regional analgesia would have similar outcomes to late regional analgesia. MethodsWe retrospectively reviewed the American College of Surgeons Trauma Quality Improvement Program database from 2017 to 2019. We included patients ≥65 years old admitted with blunt chest wall trauma who received regional analgesia. We divided patients into 2 groups: (1) early regional analgesia (within 24 hours of admission) and (2) late regional analgesia (>24 hours). The outcomes evaluated were ventilator-associated pneumonia, mortality, unplanned intensive care unit admission, unplanned intubation, discharge to home, and duration of stay. Univariable analysis and multivariable logistic regression adjusting for patient and injury characteristics, trauma center level, and respiratory interventions were performed. ResultsIn the study, 2,248 patients were included. The mean (standard deviation) age was 75.3 (6.9), and 52.7% were male. The median injury severity score (interquartile range) was 13 (9–17). The early regional analgesia group had a decreased incidence of unplanned intubation (2.7% vs 5.3%, P = .002), unplanned intensive care unit admission (4.9% vs 8.4%, P < .001), and shorter mean duration of stay (5.5 vs 6.5 days, P = .002). In multivariable analysis, early regional analgesia was associated with decreased odds of unplanned intubation (odds ratio, 0.58; 95% confidence interval, 0.36–0.94; P = .026), unplanned intensive care unit admission (odds ratio, 0.60; 95% confidence interval, 0.041–0.86; P = .006), and increased odds of discharge to home (odds ratio, 1.27; 95% confidence interval, 1.04–1.55; P = .019). After multivariable adjustment, no significant difference was found for ventilator-associated pneumonia or mortality (odds ratio, 0.60; 95% confidence interval, 0.34–1.04; P = .070). ConclusionEarly regional analgesia initiation is associated with improved outcomes in older people with blunt chest wall injuries. Geriatric trauma care bundles targeting early initiation of regional analgesia can potentially decrease complications and resource use.

The Implementation of a Rib Fracture Pathway at a Small District General Hospital to Improve Patient Care.

Background and objective Rib fractures arecommon presentations to the emergency department following blunt thoracic trauma. Despite this injury causing significant morbidity and mortality, no national guidelines existto guide the acute management of this condition. In light of this, this quality improvement project was conducted at a district general hospital (DGH) with the aim of assessing the impact of using a simple rib fracture management pathway. Methods A retrospective review of paper notes and electronic databases of patients with a recorded diagnosis of "rib fractures" were reviewed. Following this, a management pathway was designed and then implemented, which incorporated BMJ Best Practices and local hospital needs. The study then assessed the impact of the pathway. Results Prior to implementing the pathway, a total of 47 individual patients were included in the statistical analysis. Of the patients analysed, 44% were older than 65 years. Of note, 89% received regular paracetamol for analgesia, 41% received regular nonsteroidal anti-inflammatory drugs (NSAIDs), and 69% received regular opioids. Advanced analgesics such as patient-controlled analgesia (PCA) and nerve blocks were poorly used; for instance, a PCA was used in only 13% of cases. Only 6% of patients received daily pain team reviews and only 44% of patients were seen by physiotherapists within the first 24 hours. Additionally, 93% of patients who were admitted under general surgery had a STUMBL (STUdy of the Management of BLunt chest wall trauma) prognostic score >10. Post-pathway implementation, a total of 22 individual patients were included in the statistical analysis. Of them, 52% were older than 65 years. The use of simple analgesia was unchanged. However advanced analgesia was better escalated, and PCAswere used 43% of the time. The involvement of other healthcare professionals improved; 59% were reviewed by the pain team in the first 24 hours, 45% received daily pain team reviews, and 54% received advanced analgesia. Conclusion Based on our findings, implementing a simple rib fracture pathway is effective at improving the management of rib fracture patients admitted to our DGH.

Management Pathways for Traumatic Rib Fractures-Importance of Surgical Stabilisation.

Rib fractures occur in almost half of blunt chest wall trauma victims in Australia. They are associated with a high rate of pulmonary complications, and consequently, with increased discomfort, disability, morbidity, and mortality. This article summarises thoracic cage anatomy and physiology, and chest wall trauma pathophysiology. Institutional clinical strategies and clinical pathway "bundles of care" are usually available to reduce mortality and morbidity in patients with chest wall injury. This article analyses multimodal clinical pathways and intervention strategies that include surgical stabilisation of rib fractures (SSRF) in thoracic cage trauma patients with severe rib fractures, including flail chest and simple multiple rib fractures. The management of thoracic cage injury should include a multidisciplinary team approach with proper consideration of all potential avenues and treatment modalities (including SSRF) to obtain the best patient outcomes. There is good evidence for the positive prognostic role of SSRF as part of a "bundle of care" in the setting of severe rib fractures such as ventilator-dependent patients and patients with flail chest. However, the use of SSRF in flail chest treatment is uncommon worldwide, although early SSRF is standard practice at our hospital for patients presenting with multiple rib fractures, flail chest, and/or severe sternal fractures. Several studies report that SSRF in patients with multiple simple rib fractures lead to positive patient outcomes, but these studies are mostly retrospective studies or small case-control trials. Therefore, prospective studies and well-designed RCTs are needed to confirm the benefits of SSRF in patients with multiple simple rib fractures, as well as in elderly chest trauma patients where there is scant evidence for the clinical outcomes of SSRF intervention. When initial interventions for severe chest trauma are unsatisfactory, SSRF must be considered taking into account the patient's individual circumstances, clinical background, and prognostic projections.

What is the optimal care pathway for patients with blunt chest wall trauma presenting to the ED?

What is the optimal care pathway for patients with blunt chest wall trauma presenting to the ED?

Reconstructive surgery for late complications after blunt chest wall trauma

To analyze the incidence and structure of late complications after blunt chest trauma, feasibility of surgical correction and effectiveness of these interventions. Treatment outcomes were analyzed in 26 patients with late complications of blunt chest wall trauma. Severe chest deformities were diagnosed in 8 patients, non-union rib fracture - 5, pulmonary hernia - 4, chronic abscesses and pseudocysts of soft tissues of the chest - 3, osteomyelitis of the ribs - 3, chronic recurrent pulmonary bleeding following damage to lung parenchyma by rib fragments - 2, persistent post-traumatic pleuritis - in 1 patient. Among 26 patients, 23 ones underwent surgical correction of complications. Reconstructive procedures were performed in 5 out of 8 patients with post-traumatic chest deformities. In 5 patients with non-union rib fractures, surgery consisted of resection of ribs, excision of capsule and scar tissue, osteosynthesis. Thoracic pulmonary hernia required thoracotomy, viscerolysis, chest wall defect closure by bringing together the ribs and fixing with pulley sutures or ZipFix system. In 2 patients, pulmonary hernia was combined with non-union rib fracture. These patients underwent additional resection of false joints and osteosynthesis. Three patients were diagnosed with chronic abscesses and pseudocysts of soft tissues of the chest. Surgical treatment was carried out according to the principles of staged debridement of chronic purulent foci. Osteomyelitis of ribs in 3 patients required resection within intact tissues. Fixation of ribs by metal structures was not performed in these patients, and we performed only muscle and soft tissue repair. Conservative treatment was carried out in 3 patients with chest deformity. There were no lethal outcomes. Pathological syndromes in long-term period after blunt chest trauma require surgical correction. Surgical treatment of patients with late complications of chest trauma should be aimed at chest stabilization, improving respiratory function and preventing secondary and tertiary complications. Osteosynthesis allows not only to eliminate pathological syndromes, but also increase tolerance to physical activity and quality of life.

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

BackgroundOver 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...

Evaluating the effect of montelukast tablets on respiratory complications in patients following blunt chest wall trauma: A double-blind, randomized clinical trial

PurposePatients with multiple traumas are at high risk of developing respiratory complications, including pneumonia and acute respiratory distress syndrome. Many pulmonary complications are associated with systemic inflammation and pulmonary neutrophilic infiltration. Leukotriene-receptor antagonists are anti-inflammatory and anti-oxidant drugs subsiding airway inflammation. The present study investigates the effectiveness of montelukast in reducing pulmonary complications among trauma patients. MethodsThis randomized, double-blind, placebo-control trial was conducted in patients with multiple blunt traumas and evidence of lung contusion detected via CT scan. We excluded patients if they met at least one of the following conditions: < 16 years old, history of cardiopulmonary diseases or positive history of montelukast-induced hypersensitivity reactions. Patients were allocated to the treatment (10 mg of montelukast) or placebo group using permuted block randomization method. The primary measured outcome was the volume of pulmonary contusion at the end of the trial. The secondary outcomes were intensive care unit and hospital length of stay, ventilation days, multi-organ failure, and the in-hospital mortality rate. ResultsIn total, 65 eligible patients (treatment = 31, placebo = 34) were included for the final analysis. The treatment group had more pulmonary contusion volume (mean (SD), mm3) at the right (68726.97 (93656.54) vs. 59730.27 (76551.74)) and the left side (67501.71 (91514.04) vs. 46502.21 (80604.21)), higher initial C-reactive peptide level (12.16 (10.58) vs. 10.85 (17.87)) compared to the placebo group, but the differences were not statistically significant (p > 0.05). At the end of the study, the mean (SD) of pulmonary contusion volume (mm3) (right side = 116748.74 (361705.12), left side = 64522.03 (117266.17)) of the treatment group were comparable to that of the placebo group (right side = 40051.26 (64081.56), left side = 25929.12 (47417.13), p = 0.228 and 0.082, respectively). Moreover, both groups have statistically similar hospital (mean (SD), days) (10.87 (9.83) vs. 13.05 (10.12)) and intensive care unit length of stays (mean (SD), days) (7.16 (8.15) vs. 7.82 (7.48)). Of note, the frequency of the in-hospital complications (treatment vs. control group) including acute respiratory distress syndrome (12.9% vs. 8.8%, p = 0.71), pneumonia (19.4% vs. 17.6%, p = 0.85), multi-organ failure (12.9% vs. 17.6%, p = 0.58) and the mortality rate (22.6% vs. 14.7%, p = 0.41) were comparable between the groups. ConclusionAdministrating montelukast has no preventive or therapeutic effects on lung contusion or its complications.

Blunt chest wall trauma: Rib fractures and associated injuries.

Blunt injuries to the chest wall, specifically those related to rib fractures, need to be promptly identified and effectively managed to reduce patient morbidity and mortality. Furthermore, judicious use of multimodal pain management and early identification of patients who will benefit from the surgical stabilization of rib fractures are paramount to optimal outcomes.

Major Risk Factors for Mortality in Elderly and Non-Elderly Adult Patients Emergently Admitted for Blunt Chest Wall Trauma: Hospital Length of Stay as an Independent Predictor.

Background: Blunt thoracic trauma is responsible for 35% of trauma-related deaths in the United States and significantly contributes to morbidity and healthcare-related financial strain. The goal of this study was to evaluate factors influencing mortality in patients emergently admitted with the primary diagnosis of blunt chest wall trauma. Methods: Adults emergently admitted for blunt chest trauma were assessed using the National Inpatient Sample Database, 2004–2014. Data regarding demographics, comorbidities, and outcomes were collected. Relationships were determined using univariable and multivariable logistic regression models. Results: In total, 1120 adult and 1038 elderly patients emergently admitted with blunt chest trauma were assessed; 46.3% were female, and 53.6% were male. The average ages of adult and elderly patients were 46.6 and 78.9 years, respectively. Elderly and adult patients both displayed mortality rates of 1%. The regression model showed HLOS and several comorbidities as the main risk factors of mortality Every additional day of hospitalization increased the odds of mortality by 9% (OR = 1.09, 95% CI = 1.01–1.18, p = 0.033). Mortality and liver disease were significantly associated (OR = 8.36, 95% CI = 2.23–31.37, p = 0.002). Respiratory disease and mortality rates demonstrated robust correlations (OR = 7.46, 95% CI = 1.63–34.11, p = 0.010). Trauma, burns, and poisons were associated with increased mortality (OR = 3.72, 95% CI = 1.18–11.71, p = 0.025). The presence of platelet/white blood cell disease correlated to higher mortality. (OR = 4.42, 95% CI = 1.09–17.91, p = 0.038).

The clinical effectiveness of the STUMBL score for the management of ED patients with blunt chest trauma compared to clinical evaluation alone

The STUMBL (STUdy of the Management of BLunt chest wall trauma) score is a new prognostic score to assist ED (Emergency Department) decision making in the management of blunt chest trauma. This is a retrospective cohort chart review study conducted in a UK University Hospital ED seeing 120,000 patients a year, comparing its performance characteristics to ED clinician judgement. All blunt chest trauma patients that presented to our ED over a 6-month period were included. Patients were excluded if age < 18, if they had immediate life-threatening injury, required critical care admission for other injuries or in case of missing identification data. Primary endpoint was complication defined as any of lower respiratory tract infection, pulmonary consolidation, empyema, pneumothorax, haemothorax, splenic or hepatic injury and 30-day mortality. Clinician judgement (clinician decision to admit) and STUMBL score were compared using the receiver-operating curve (ROC) and sensitivity analysis. Three hundred and sixty-nine patients were included. ED clinicians admitted 95 of 369 patients. ED clinician decision to admit had a sensitivity of 83.9% and specificity of 86.0% for predicting complications. STUMBL score ≥ 11 had a sensitivity of 79.0% and specificity of 77.9% for the same and would have led to 117 of 369 patients being admitted. Area under the curve (AUC) of STUMBL score and ED clinician decision to admit was 0.84 (95% CI 0.78–0.90) and 0.85 (95% CI 0.79–0.91), respectively. Our findings show that a STUMBL score ≥ 11 performs no better than ED clinician judgement and leads to more patients being admitted to hospital.

Early exercise in blunt chest wall trauma: protocol for a mixed-methods, multicentre, parallel randomised controlled trial (ELECT2 trial)

IntroductionChronic pain and disability are now well-recognised long-term complications of blunt chest wall trauma. Limited research exists regarding therapeutic interventions that can be used to address these complications. A recent...

Comparison of chest CT scan findings between COVID-19 and pulmonary contusion in trauma patients based on RSNA criteria: Established novel criteria for trauma victims

ProposeIn this study, we re-assessed the criteria defined by the radiological society of North America (RSNA) to determine novel radiological findings helping the physicians differentiating COVID-19 from pulmonary contusion. MethodsAll trauma patients with blunt chest wall trauma and subsequent pulmonary contusion, COVID-19-related signs and symptoms before the trauma were enrolled in this retrospective study from February to May 2020. Included patients (Group P) were then classified into two groups based on polymerase chain reaction tests (Group Pa for positive patients and Pb for negative ones). Moreover, 44 patients from the pre-pandemic period (Group PP) were enrolled. They were matched to Group P regarding age, sex, and trauma-related scores. Two radiologists blindly reviewed the CT images of all enrolled patients according to criteria defined by the RSNA criteria. The radiological findings were compared between Group P and Group PP; statistically significant ones were re-evaluated between Group Pa and Group Pb thereafter. Finally, the sensitivity and specificity of each significant findings were calculated. The Chi-square test was used to compare the radiological findings between Group P and Group PP. ResultsIn the Group PP, 73.7% of all ground-glass opacities (GGOs) and 80% of all multiple bilateral GGOs were detected (p < 0.001 and p = 0.25, respectively). Single bilateral GGOs were only seen among the Group PP. The Chi-square tests showed that the prevalence of diffused GGOs, multiple unilateral GGOs, multiple consolidations, and multiple bilateral consolidations were significantly higher in the Group P (p = 0.001, 0.01, 0.003, and 0.003, respectively). However, GGOs with irregular borders and single consolidations were more significant among the Group PP (p = 0.01 and 0.003, respectively). Of note, reticular distortions and subpleural spares were exclusively detected in the Group PP. ConclusionWe concluded that the criteria set by RSNA for the diagnosis of COVID-19 are not appropriate in trauma patients. The clinical signs and symptoms are not always useful either. The presence of multiple unilateral GGOs, diffused GGOs, and multiple bilateral consolidations favor COVID-19 with 88%, 97.62%, and 77.7% diagnostic accuracy.

Management of rib fractures following blunt chest wall trauma: Are we there yet?

Management of rib fractures following blunt chest wall trauma: Are we there yet?

Intercostal liposomal bupivacaine injection for rib fractures: A prospective randomized controlled trial.

Blunt chest wall injury accounts for 15% of trauma admissions. Previous studies have shown that the number of rib fractures predicts inpatient opioid requirements, raising concerns for pharmacologic consequences, including hypotension, delirium, and opioid dependence. We hypothesized that intercostal injection of liposomal bupivacaine would reduce analgesia needs and improve spirometry metrics in trauma patients with rib fractures. A prospective, double-blinded, randomized placebo-control study was conducted at a Level I trauma center as a Food and Drug Administration investigational new drug study. Enrollment criteria included patients 18 years or older admitted to the intensive care unit with blunt chest wall trauma who could not achieve greater than 50% goal inspiratory capacity. Patients were randomized to liposomal bupivacaine or saline injections in up to six intercostal spaces. Primary outcome was to examine pain scores and breakthrough pain medications for 96-hour duration. The secondary endpoint was to evaluate the effects of analgesia on pulmonary physiology. One hundred patients were enrolled, 50 per cohort, with similar demographics (Injury Severity Score, 17.9 bupivacaine 17.6 control) and comorbidities. Enrolled patients had a mean age of 60.5 years, and 47% were female. Rib fracture number, distribution, and targets for injection were similar between groups. While both groups displayed a decrease in opioid use over time, there was no change in mean daily pain scores. The bupivacaine group achieved higher incentive spirometry volumes over Days 1 and 2 (1095 mL, 1063 mL bupivacaine vs. 900 mL, 866 mL control). Hospital and intensive care unit lengths of stay were similar and there were no differences in postinjection pneumonia, use of epidural catheters or adverse events bet ween groups. While intercostal liposomal bupivacaine injection is a safe method for rib fracture-related analgesia, it was not effective in reducing pain scores, opioid requirements, or hospital length of stay. Bupivacaine injection transiently improved incentive spirometry volumes, but without a reduction in the development of pneumonia. Therapeutic/care management, Level II.

Admission Lymphopenia is Associated With Discharge Disposition in Blunt Chest Wall Trauma Patients

Lymphopenia contributes to the immune suppression observed in critical illness. However, its role in the immunologic response to trauma remains unclear. Herein, we assessed whether admission lymphopenia is associated with poor outcomes in patients with blunt chest wall trauma (BCWT). All adult patients with a Chest Abbreviated Injury Score (CAIS) ≥2 admitted to our Level I Trauma center between May 2009 and December 2018 were identified in our institution Trauma Registry. Patients with absolute lymphocyte counts (ALC) collected within 24 H of admission were included. Patients who died within 24 H of admission, had bowel perforation on admission, penetrating trauma, and burns were excluded. Demographics, injury characteristics, comorbidities, ALC, complications, and outcomes were collected. Lymphopenia was defined as an ALC ≤1000/µL. Association between lymphopenia and clinical outcomes of BCWT was assessed using multivariate analyses. P < 0.05 was considered significant. A total of 1394 patients were included; 69.7% were male; 44.3% were lymphopenic. On univariate analysis, lymphopenia was associated with longer in-hospital stay (11.6±10.2 versus 10.1±11.4, P=0.009), in-hospital death (9.7% versus 5.8%, P=0.006), and discharge to a healthcare facility (60.9% versus 46.4%, P < 0.001). Controlling for Injury Severity Score, age, gender, and comorbidities, the association between lymphopenia and discharge to another facility (SNF/rehabilitation facility/ACH) (OR=1.380 [1.041-1.830], P=0.025) remained significant. Lymphopenia on admission is associated with discharge requiring increased healthcare support. Routine lymphocyte count monitoring on admission may provide important prognostic information for BCWT patients.

A survey of current practice in UK emergency department management of patients with blunt chest wall trauma not requiring admission to hospital

IntroductionThere is no universal agreement or supporting evidence for the content or format of a standardised guidance document for patients with blunt chest wall trauma. The aim of this study is to investigate current UK Emergency Medicine practice of the management of patients with blunt chest wall trauma, who do not require admission to hospital. MethodsThis was a cross-sectional survey study, with mixed quantitative / qualitative analysis methods. A convenience sample of all professions working in the Emergency Departments / Urgent Care Centres in the UK was used. A combination of closed and open-ended questions were included, covering demographics and current practice in the respondent's main place of work. Themes explored included management strategies for safe discharge home, risk prediction and variables considered relevant for inclusion in patient guidance. ResultsA total of 113 clinicians responded from all UK trauma networks, including all devolved nations. A total of 20 different risk prediction tools / pathways were reported to be used when assessing whether a patient is safe for discharge home, with over 35 different variables listed by respondents as being important to highlight to patients. Qualitative analysis revealed that a small number of respondents believe patients can be better managed through the improvement of the following; identification of the high-risk patient, initial assessment and current management strategies used in the ED / UCC. DiscussionThe wide variation in practice highlighted in this study may be due in part to a lack of national consensus guidelines on how to manage this complex patient group. Further research is needed into whether structured national guidelines for the assessment and management of such patients could potentially lead to an overall improvement in outcomes. Such guidelines should be developed by not only expert clinicians and researchers, but also and more importantly by those service-users who have lived experience of blunt chest wall trauma.