Makindo Medical Notes.com

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina |Rib Fracture Score

Introduction

• Traumatic rib fractures are common, resulting from significant forces impacting on the chest, and are associated with significant morbidity and mortality.
• Respiratory complications, including pneumonia, are common in up to 31% of patients.
• Prompt multi-modal analgesia incorporating regional analgesia, i.v. opioids, and oral adjuncts are essential to reduce complications.
• Operative fixation is indicated in some instances.

Risk factors

• Elderly but can be seen in children and all ages
• Road traffic accidents, seat belt
• Weakened bones: inherited conditions, osteoporosis, total sternectomy, and multiple myeloma

Epidemiology

• Rib fractures detected in at least 10% of all injured patients
• 75% due to blunt thoracic trauma with RTC being the main cause.
• 25% are due to penetrating injuries.
• Associated with significant morbidity needing ICU
• Mortality rates as high as 33%

Pathophysiology: 3 main issues

• Hypoventilation due to pain: reduces tidal volume and results in atelectasis and difficult to expectorate secretions and pneumonia
• Impaired gas exchange in damaged lung underlying the fractures. Severe injury esp with flail segment can cause lung contusion and even necrosis with intrapulmonary shunting
• Altered breathing mechanics: with a flail floating segment it is not possible to generate negative intrapleural pressure as rib section moves in while the rest of the ribcage moves outward. Reduces tidal volume and PO₂

Associated Combinations of Injuries

• Clavicle, 1st and 2nd ribs, subclavian vessels, aorta, trachea, main bronchus, spinal cord or brachial plexus
• Sternum, myocardium, greater vessels, upper thoracic spine
• Right lower ribs, liver and right kidney injury
• Left lower ribs, damage to spleen and left kidney

Rib fractures and related organs at risk of trauma

• 1st rib: apex of lungs and subclavian vessels
• 2nd rib: ascending aorta, superior vena cava trauma
• 10th rib: diaphragm, liver, spleen
• 11th rib: diaphragm, liver, spleen
• 12th rib: renal injury

Flail Chest

• If a rib is broken in two places, then the free-floating section will no longer be able to support the underlying lung or move with the usual expansion of the ribs.
• Such damage means the underlying lung will not expand or contract, and therefore not take part in gas exchange this is called a flail segment.
• The flail segment moves in the opposite direction to the rest of the chest wall: because of the ambient pressure in comparison to the pressure inside the lungs, it goes in while the rest of the chest is moving out, and vice versa.
• This so-called "paradoxical breathing" is painful and increases the work involved in breathing resulting in hypoventilation. There may also be underlying lung damage and bruising due to the trauma.

Calculate the Rib Fracture Score

Myocardial Contusion

• Seen with sternal fractures and blunt deceleration injuries#
• Can be asymptomatic or some have chest pain or right ventricular dysfunction. Tachycardia and Raised JVP
• CK and Troponin may be elevated
• ECG may be some changes - sinus tachycardia, ectopic, BBB, ST and T wave changes, ST elevation.
• If unstable arrhythmias or hypotension admit to CCU or HDU and monitor and get an Echocardiogram

Investigations

• FBC, U&E, LFT, Amylase, Lactate, ABG
• ECG, CK, Troponin
• CT Traumogram chest

A 3D CT reconstruction of the chest wall

Management: Calculate the Rib Fracture Score

• ABC, Oxygenate (Unless COPD) 94-98% and analgesia. Identify and treat any tension pneumothorax with decompression and chest drain. Regular PO analgesia / NSAIDs if not CI ? PPI. Analgesic ladder
  • Paracetamol 1 g 6h PO/IV
  • Ibuprofen 400 mg 8h + PPI
  • Lidocaine plaster 5%
  • MST 5 mg 12 h PO
  • Oramorph 10-20 mg PO PRN or Dihydrocodeine 30 mg 4h PRN
  • Consider Gabapentin PO
  • Lignocaine patch 5%
  • Consider others e.g. Gabapentin
  • IF RFS > 5 then also consider Morphine PCA: contact anaesthetics
  • If RFS > 10: Involve on call physio, consider regional anaesthesia such as thoracic epidural or paravertebral block which will need an INR and platelet check first. Discuss need for ITU with ITU SPR
  • Respiratory Physio especially if RFS>7 and/or unable to cough or take a deep breath to be seen in less than 8 hrs.
• Refer to critical care if
  • RFS 10 or more
  • Flail chest or rib fractures with pneumothorax
  • Clinical deterioration
  • SpO₂ <94%, RR >30
  • FiO₂ requirements 40% and/or increasing
  • Presence of significant respiratory or cardiac disease

Surgical Repair of Flail Chest

• Indicated for Intubated patients with a flail chest, respiratory failure, and prolonged ventilation, or non-intubated patients with a flail with deteriorating pulmonary function, are now considered for operative fixation.
• The aim is to stabilize the chest to restore pulmonary mechanics and reduce pain

Epidurals

• Uses and those who are likely to benefit
  • Patients with higher rib fractures
  • Multilevel or bilateral fractures
  • Flail chests, intercostal drains
  • Functional respiratory compromise secondary to pain benefit most from epidurals
• Contraindications
  • Absolute
    • Patient refusal
    • Spinal cord injury
    • Epidural or spinal cord haematoma
    • Thoracic vertebral body fracture
    • Spinal injury awaiting assessment
    • Coagulopathy (platelets <50×109 litre-1, INR>1.5)
    • Local infection or sepsis
    • Allergy to local anaesthetic
  • Relative
    • Lack of experience as technically challenging to insert, with a risk of dural puncture or spinal cord injury.
    • Inability to position patient due to associated injuries
    • Severe traumatic brain injury
    • Unstable lumbar or cervical spinal fractures
    • Anticoagulant therapy
    • Platelet count 50–100 × 10⁹/litre
    • Hypotension
    • Hypovolaemia
  • Adverse effects
    • Hypotension
    • If opioids used, urinary retention and pruritus.
    • Motor block and are unable to mobilize with an epidural in situ.

References

• Fantastic review on Rib fracture management