Blunt thoracic trauma (BTT) is a significant cause of morbidity and mortality. BTT is comprised of many injuries including but not limited to; rib fractures, pulmonary contusion, sternal fractures, pneumothorax, hemothorax, flail chest and soft tissue injury.
The
most common injury we manage in BTT is rib fracture. Morbidity and mortality increases as the number of rib
fractures increase. Associated
pulmonary compromise occurs with rib fractures, including pulmonary
insufficiency that can lead to respiratory failure. Pulmonary complications occur in up to one-third of BTT
patients and pneumonia in 30% of cases[1-3].
Mortality
is indirectly related to the rib fracture(s) but more directly a result of the
respiratory embarrassment that can lead to pneumonia and/or requirement for
mechanical ventilation[3-5] and this effect is more pronounced in
those aged ≥ 65 [1, 6-8].
Treatment
for BTT varies upon the patient, type of injury and experience/resources of the
center. Typically rib fractures
without significant displacement and/or restriction of the thoracic cage are
treated with aggressive pulmonary toilet and pain control. The type of analgesia
regimen is dependent upon many variables, including age, number of rib
fractures, degree of pulmonary insufficiency and concomitant injuries. The Eastern Association for the Surgery
of Trauma (EAST.org) has a practice management guideline based on an exhaustive
review of the literature. Their
recommendations are as follows for BTT, published in the Journal of Trauma,
59(5):1256-1267, November 2005 (http://www.east.org/resources/treatment-guidelines/blunt-thoracic-trauma-(btt),-pain-management-in )
Level 1
1.
Epidural analgesia is the optimal modality of pain relief for blunt
chest wall injury and is the preferred technique after severe blunt thoracic
trauma.
Level II
1.
Patients with 4 or more rib fractures who are>65 years of age should
be provided with epidural analgesia unless this treatment is contraindicated.
2.
Younger patients with 4 or more rib fractures or patients aged>65
with lesser injuries should also be considered for epidural analgesia.
Level III
1.
The approach for pain management in BCT requires individualization for
each patient. Clinical performance measures (pain scale, pulmonary exam /
function, ABG) should be measured as judged appropriate at regular intervals.
2.
Presence in elderly patients of cardiopulmonary disease or diabetes
should provide additional impetus for epidural analgesia as these
comorbidities may increase mortality once respiratory complications have
occurred.
3.
Intravenous narcotics, by divided doses or demand modalities may be used
as initial management for lower risk patients presenting with stable and
adequate pulmonary performance as long as the desired clinical response is
achieved.
4.
High-risk patients who are not candidates for epidural analgesia should
be considered for paravertebral (extrapleural) analgesia commensurate with
institutional experience.
A
specific recommendation cannot be made for intrapleural or intercostal
analgesia based on the available evidence but its’ apparent safety and efficacy
in the setting of thoracic trauma has been reported.
Mechanical
stabilization of rib fractures is reserved for those patients with severe BTT
and flail segments. Open reduction
and internal fixation (ORIF) depends largely on the degree of chest deformity
and pulmonary embarrassment. Patients must have aggressive pain control, often
with epidural or paravertebral analgesia.
If these patients still have poor pulmonary reserve or pending
respiratory failure they should be considered for ORIF of the thoracic cage and
sternum as indicated, see our algorithm for chest wall fixation.
NOTE
ON FOLEY’S-Thoracic epidurals do not specifically require Foley
catheterization. If criteria for discontinuation are otherwise met, the Foley
should be removed. If urinary retention occurs, replace the Foley.
References:
1.
Ziegler AW, Agarwal NN: Morbidity and Mortality of Rib
Fractures. J Trauma. 1994;37:975-979
2.
Bolliger CT, Van Eeden SF. Treatment of multiple rib fracture:
randomized controlled trial comparing ventilatory with nonventilatory
management Chest 1990;97:943-948
3.
Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in
the elderly. J Trauma . 2000;48:1040-1047
4.
Barnea Y, Kashtan H, Shornick Y, Werbin N. Isolated rib
fractures in elderly patients: morality and morbidity. Can J Surg.
2002;45:43-46
5.
Clark GC, Schecter WP, Trunkey DD. Variables affecting outcome
in blunt chest trauma: Flail chest vs pulmonary contusion. J Trauma. 1988;28:298-304
6.
Svennevig JL, Bugge-Asperheim B, Geiran OR, et al. Prognostic
factors in blunt chest trauma: analysis of 652 cases. Ann Chir Gynaecol. 1986;75:8-14
7.
Shorr RM, Rodriguez A, Indeck MC, Crittenden MD, Hartunian S,
Cowley RA. Blunt chest trauma in the elderly. J Trauma 1989;29: 234-237
8.
Cameron P, Dziukas L, Hadj A, Clark P, Hooper S. rib fractures
in major trauma Aust N Z J Surg. 1996;66:530-534
