Management Of Rib Fractures Research Articles

Early Serratus Plane Block for Rib Fracture Management could Avoid Intensive Care Unit Admission.

How to cite this article: Gorecha M, Menon A, Woodford E, Yahia S, Marimuthu K. Early Serratus Plane Block for Rib Fracture Management could Avoid Intensive Care Unit Admission. Indian J Crit Care Med 2020;24(10):995.

Does Operative Management of Rib Fractures Improve Outcomes in Geriatric Patients?

Alejandro Aldana, Jose MD; Xinyue Zhang, Christina MD; Alejandro Fonseca, Ricardo MD; Canas, Melissa MD; Kiran Rasane, Rohit MD; Enrique Rincon, Javier MD; Afzal, Hussain MD; Ghosh, Esha MS; Houston Hoofnagle, Mark MD PhD; Vincent Bochicchio, Grant MD, FACS Author Information

Do Lidocaine Patches Reduce Opioid Use in Acute Rib Fractures?

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

The complex case of rib fracture management in older people

Rib fractures remain a common result of falls, increasing morbidity and mortality. Effective analgesia is crucial in the management of such cases, and preventative measures are essential. Sarah Jane Palmer elaborates

LO93: A single center randomized control trial of intravenous lidocaine for the management of traumatic rib fractures

Introduction: Traumatic rib fractures (RF) are a common occurrence with 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and reducing morbidity and mortality. There is evidence of intravenous (IV) lidocaine's effectiveness and safety in the post-operative thoracic and abdominal surgical patient and we hypothesize that it may be ideal in trauma patients with RF. We evaluated IV lidocaine's analgesic efficacy in this population. Methods: A single-centre, double-blind, randomized control trial comparing a 72-96 hour IV lidocaine infusion plus standard analgesics to placebo infusion plus standard analgesics. Participants were adult trauma patients diagnosed with two or more RFs requiring hospital admission. A total of 36 patients were enrolled over 5 months in 2019. The study was powered to detect a 20% reduction in pain scores, which is determined to be clinically significant. Results: The primary outcome was mean pain score at rest and with movement, as measured on the Visual Analog Scale (VAS). There were consistent trends toward reduced VAS pain scores at rest and with movement in the lidocaine group as compared to placebo group with mean scores of 3.49 [SD 2.02 95% CI] and 7.08 [SD 1.71 95% CI] in the lidocaine group and 3.83 [SD 1.93 95% CI] and 8.03 [SD 1.44 95% CI] in the placebo group, at rest (p value 0.624) and with movement (p value 0.110), respectively . Secondary outcomes were patient satisfaction as measured on the VAS which demonstrated a score of 7.79 [SD 1.82 95% CI] in the lidocaine group and 6.63 [SD 1.77 95% CI] (p = 112) in the placebo group, and total morphine equivalents (ME) used (including breakthrough doses) that demonstrated a trend towards a reduction in the lidocaine group with 210.9 mg [SD 180.0 95% CI] compared to the placebo with total ME used of 309.9 mg [SD 221.8 95% CI]. Other secondary outcomes were protocol adherence, incidence of respiratory failure, hospital and ICU length of stay, mortality, incidence of lidocaine toxicity, and treatment regimens (non-opioid analgesics). Conclusion: These results demonstrate a trend towards lidocaine's analgesic benefit during rest and the critical times of patient movement and mobility, which has been demonstrated to be paramount in the reduction of respiratory complications from rib fractures. The results also tend towards a reduction in morphine equivalents, although the trial was not powered to demonstrate this

Multicenter longitudinal cross-sectional study comparing effectiveness of serratus anterior plane, paravertebral and thoracic epidural for the analgesia of multiple rib fractures

BackgroundThere is a paucity of data comparing effectiveness of various techniques for pain management of traumatic rib fractures. This study compared the quality of analgesia provided by serratus anterior plane...

Variation in Adherence to Guideline Recommendations for Management of Rib Fractures

Rib fractures are associated with significant morbidity and mortality, particularly in older patients. Professional society guidelines recommend the

Association Between Adherence to Evidence-Based Practices for Treatment of Patients With Traumatic Rib Fractures and Mortality Rates Among US Trauma Centers

IMPORTANCERib fractures are sustained by nearly 15% of patients who experience trauma and are associated with significant morbidity and mortality. Evidence-based practice (EBP) rib fracture management guidelines and treatment algorithms have been published. However, few studies have evaluated trauma center adherence to EBP or the clinical outcomes of each practice within a national cohort.OBJECTIVETo examine adherence to 6 EBPs for rib fractures across US trauma centers and the association with in-hospital mortality.DESIGN, SETTING, AND PARTICIPANTSA retrospective cohort study was conducted from January 1, 2007, to December 31, 2014, of 777 US trauma centers participating in the National Trauma Data Bank. A total of 625 617 patients (age, ≥16 years) were evaluated. Patients without rib fractures and those with no signs of life or institutions with poor data quality were excluded. Data analysis was performed from January 1, 2007, to December 31, 2014.MAIN OUTCOMES AND MEASURESSix EBPs were defined: (1) neuraxial blockade, (2) intensive care unit admission, (3) pneumatic stabilization, (4) chest computed tomographic scans for older adults (≥65 years) with 3 or more rib fractures, (5) surgical rib fixation for flail chest, and (6) tube thoracostomy placement for hemothorax and/or pneumothorax. Multiple imputation was used to account for missing data. Patients were propensity score matched in a 1:1 fashion based on demographic characteristics; injury severity parameters, including the Injury Severity Score (range, 0–75; higher scores indicate more severe injuries); and comorbidities. Logistic regression was used to determine the association of each practice with all-cause in-hospital mortality.RESULTSOf the 625 617 patients with rib fractures included in this analysis, 456 196 patients (73%) were white and 432 229 patients (69%) were male; the median age of the patients was 51 (interquartile range, 37–65) years, and the mean (SD) Injury Severity Score was 18.3 (11.1). The mean (SD) number of rib fractures was 4.2 (2.6). On univariate analysis, patients treated at verified level I trauma centers were more likely to receive 5 or 6 EBPs (all but pneumatic stabilization). Of those who met eligibility, only 4578 of 111 589 patients (4%) received neuraxial blockade, 46 456 of 111 589 patients (42%) were admitted to the intensive care unit, 3302 of 24 319 patients (14%) received surgical rib fixation, 1240 of 111 589 patients (1%) received pneumatic stabilization, 109 160 of 258 334 patients (42%) received tube thoracostomy, and 32 405 of 81 417 patients (40%) received chest computed tomographic scans. Three EBPs were associated with decreased mortality: neuraxial blockade (odds ratio [OR], 0.64; 95% CI, 0.51–0.79; P < .001) for patients aged 65 years or older with 3 or more rib fractures, surgical rib fixation (OR, 0.13; 95% CI, 0.01–0.18; P < .001), and intensive care unit admission (OR, 0.93; 95% CI, 0.86–1.00; P = .04) for patients aged 65 years or older with 3 or more rib fractures. Pneumatic stabilization (OR, 1.71; 95% CI, 1.25–2.35; P < .001) and chest tube placement (OR, 1.27; 95% CI, 1.21–1.33; P < .001) were associated with increased mortality in older patients with 3 or more rib fractures. On multivariable analysis, insurance status, race/ethnicity, injury severity, hospital bed size, and trauma center verification level were associated with receiving EBPs for rib fractures.CONCLUSIONS AND RELEVANCESignificant variation appears to exist in the delivery of EBPs for rib fractures across US trauma centers. Three EBPs were associated with reduced mortality, but EBP adherence was poor. Multiple factors, including trauma center verification level, appear to be associated with patients receiving EBPs for rib fractures.

Pain Management for Traumatic Rib Fractures with ESP Block in ICU

Rib fractures are common injuries in blunt chest trauma, that cause severe thoracic pain, which limits patients' ability to cough and breathe deeply, which can lead to atelectasis and pneumonia. Various treatments for pain management of rib fractures have been described such as analgesics and regional anaesthesia. The ultrasound-guided erector spinae plane block (ESP) is a novel myofascial plane block for thoracic analgesia after thoracic or abdomen surgery. It is simple to perform the block because the key landmarks of tip of transverse processes and erector spinae muscle are easily visualised on ultrasound. This also allows to treat patients more easily in intensive care unit (ICU). We present a case that used ESP for pain management related to traumatic multiple rib fractures and prevented pulmonary complications with ESP block in ICU.

外傷性肋骨骨折に対し超音波ガイド下持続椎弓後面ブロックにて疼痛管理を行った1症例(Continuous ultrasound–guided retrolaminar block for pain management in a patient with traumatic rib fractures)

要旨 外傷性肋骨骨折に対し，持続椎弓後面ブロック（retrolaminar block: RLB）にて疼痛管理を施行した症例を経験したので報告する。48歳の女性。身長159cm，体重50kg。外傷性左第4–7肋骨骨折に対し椎弓後面ブロックを施行した。超音波ガイド下にTh4–5椎弓後面に1%リドカインと0.75%ロピバカイン（ROP）の混合液20mLを注入後，薬液でできたスペースにX線不透過性カテーテルを挿入留置し，0.2% ROP持続投与を開始した。ブロック前後で，安静時NRSは3/10から0/10へ，体動時NRSは8/10から2/10へ低下した。ROP持続注入はブロック施行後4日まで継続し，安静時のNRSは3/10以下で管理することが可能であった。持続RLBを行う際には，超音波ガイド下にてカテーテルを留置し，胸部X線写真にてカテーテル位置確認することで，良好な疼痛管理を行えると考えられる。超音波ガイド下RLBは簡便であり，硬膜外鎮痛方法に比べ重篤な合併症が少ないことから，胸部外傷に対する鎮痛方法の選択肢の一つとして考えられる。

Testing the clinical validity of the Bemelman Rib Fracture Management Guideline.

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

Surgical management of rib fractures in chest wall trauma

Chest wall trauma along with resulting pulmonary complications are associated with considerable morbidity and mortality. Non-surgical treatment of rib fractures has represented the gold standard for the past few decades but a new trend towards operative management has been encouraged by many surgeons who aimed to reduce morbidity, mortality and hospital length of stay (LOS). Indications, patient selection and timing of surgical stabilization of rib fractures (SSRF) remains still debated and the results of international conducted surveys show a large variability in decision-making. In this article, we discuss the state of the art of surgical management of traumatic rib fractures.

New horizons in rib fracture management in the older adult.

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

Anatomy of the Ribs and Management of their Fractures as Viewed by Avicenna (980-1037 Ad)

Avicenna statedinteresting points on the symptoms of rib bone fractures, their physical examination, and also treatment and management of the complications in his master piece Canon in Tibb. We reviewed Avicenna's Canon and his viewpoints on the anatomy of the rib bones and their fractures and compared it with conventional medicine. He described the ana omy of the ribs; he explained the effectiveness of their structure in the prote tion of vital organs. He also suggested some methods for the management of rib fractures, such as using vacuum at the fracture site or open surgery in case of complications. Avicenna's point of view on the approach toward rib fractures had some similarities and differences with conventional practice. Some of his suggestions could be taken into account.

Alternative Regional Anesthesia for Surgical Management of Multilevel Unilateral Rib Fractures

RIB FRACTURES are a frequent occurrence in trauma victims. 1 Lafferty P.M. Anavian J. Will R.E. et al. Operative treatment of chest wall injuries: Indications, technique, and outcomes. J Bone Joint Surg Am. 2011; 93: 97-110 Crossref PubMed Scopus (137) Google Scholar Patients with a “flail chest” pattern of injury, defined as 2 fractures per rib in 3 (or more) consecutive ribs, often struggle with hypoxemic respiratory failure related to inefficient ventilatory mechanics, inability to expectorate, underlying pulmonary contusion, and subsequent pneumonia. The operative indications for rib fracture repair have not been established and are considered to be an issue of debate. 2 Mitchell J.D. Blunt chest trauma: Is there a place for rib stabilization?. J Thorac Dis. 2017 Apr; 9: S211-S217 Crossref PubMed Scopus (13) Google Scholar

Surgical management of rib fractures

Surgical management of rib fractures

Management of rib fractures.

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.

Ketamine infusion for pain control in elderly patients with multiple rib fractures: Results of a randomized controlled trial.

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. 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. 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. 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. Therapeutic, level I.

Erector spinae plane vs. paravertebral blockade for rib fracture analgesia

We would like to commend Adhikary et al. for their continued efforts to show benefit from novel regional techniques for chest trauma 1 and agree that patients with rib fracture(s) have significantly improved pain scores after regional analgesia. We would like to invite the authors to reply to a number of comments that we have about their work. Firstly, the authors make several comments about the technically challenging nature of paravertebral blockade. In our institution, ultrasound-guided thoracic paravertebral blockade is the regional technique of choice in unilateral chest trauma. Data from our experiences reveal an extremely low complication rate, with no significant complications from 314 paravertebral catheters over a 4-year period 1, inserted by consultant and registrar anaesthetists. This is consistent with our experience of thousands of single-shot blocks performed for breast surgery, and with similar experiences in other centres worldwide 2. We recognise that there is, undoubtedly, a learning curve associated with the paravertebral technique, but we believe this is similar in appearance to learning curves for any other new regional anaesthetic technique. Secondly, we note that only 79 patients were administered an erector spinae plane (ESP) block over 19 months. Can we ask whether there were other patients in the authors’ institution that received epidural or paravertebral blockade during this time, and whether comparative analysis has been possible? We are not aware of any published evidence that the ESP block is technically easier, and the results of any such analysis would be useful to know when organising training. Are there novices or non-anaesthetists performing the ESP block at the authors’ institution? Thirdly, the authors question the feasibility of paravertebral blockade in coagulopathy and haemodynamic instability. In our opinion, neither coagulopathy nor anticoagulation is a contra-indication to paravertebral techniques, necessarily. We assess each case individually, in line with the collaborative guideline from on regional anaesthesia techniques in patients with abnormalities of coagulation 3. This guideline classifies paravertebral block as ‘higher risk’ compared with more peripheral or superficial techniques, but provides no quantification of this risk, and does not reference any evidence documenting complications in patients with disorders of coagulation. Furthermore, we can find no case reports of spinal or epidural haematomas following ultrasound-guided paravertebral block performance. The practice of using curled catheters rather than straight in the paravertebral space further reduces the risk of accidental epidural placement. Our experience also reveals no associated haemodynamic instability following paravertebral blockade. Their analysis revealed a statistically significant increase in spirometry values, but such improvement would be expected normally over time, with or without regional anaesthesia. Are the authors confident about ascribing causality between the block and the spirometry improvement, given the 24-h gap between insertion and measurement? In our experience, spirometry improves very soon (within 30 min) after block insertion, and often improves further by the following day. We suggest that paravertebral block overcomes the variability in analgesia observed in the authors’ study, because it places local anaesthetic in close proximity to the target nerves, can be performed by a range of anaesthetist grades, is associated with minimal complications and side-effects, and performance of which is contra-indicated in very few patients. Regardless of the block choice however, we agree with the authors that good analgesia (under the aegis of a comprehensive pain service) remains critical in the successful management of rib fractures.

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

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