Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol

Witt, Cordelie E.; Bulger, Eileen M.

doi:10.1136/tsaco-2016-000064

Cited by 148 publications

(154 citation statements)

References 52 publications

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“…In the study conducted by Sirmali et al 86.3% of patients who died following blunt chest trauma had rib fractures equal to or greater than six. Furthermore, bilateral rib fractures are associated with a higher incidence of chest‐related morbidity and mortality due to codominant lung and parenchymal injury, with the incidence of chest‐related death increasing significantly when bilateral fractures are present.…”

Section: Discussionmentioning

confidence: 99%

“…Characteristic of rib injury, pain and altered chest wall mechanics can result in decreased pulmonary function and as such contribute to secondary pulmonary sequelae . A diminished gas exchange combined with a limited ability to clear pulmonary secretions means that the incidence of atelectasis and thus the development of pneumonia are greatly increased . It has been argued in the literature that knowledge of the presence of rib fracture can allow for the administration of pain management via analgesics, in turn reducing complications from altered chest wall mechanism .…”

Section: Discussionmentioning

confidence: 99%

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Ultrasound in the diagnosis of rib fracture following blunt chest trauma: a case study

Napier

2019

Sonography

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Rib fracture is reported to be the most commonly encountered aetiology following blunt chest trauma, 1,2 but despite this, it is frequently regarded as insignificant. Unfortunately, this ideology is compounded when the limitations of conventional imaging modalities are evaluated. In the acute setting, plain radiography can render rib fractures undetected in 50% of cases, 3 and although computer tomography (CT) is deemed to have a higher sensitivity than plain film, its limitations can include a lower specificity in the setting of higher radiation doses. 4,5 Regarded as being a sentinel injury, a rib fracture can act as an external marker to more serious pathologies 5-7 which can in turn compromise the normal breathing mechanism and/or the status of the thoraco-abdominal organs. As delayed diagnosis can result in increased patient morbidity and mortality, resulting from both primary and secondary complications, the detection of rib fracture is imperative in not only predicting patient outcomes but in the development of appropriate management pathways. 2,8 The aim of this case study is therefore twofold-it evaluates the sequelae that can result from rib fracture irrespective of how trivial the injury may seemand in doing so acknowledges the importance of correctly identifying this pathology in the acute setting. Secondly, it highlights a case where ultrasound detected rib fractures not seen on original plain radiographs, but suspected on magnetic resonance imaging (MRI) in a setting where CT of the chest was not performed. | CASE DESCRIPTIONA 37-year-old female presented to the emergency department following a high-speed motor vehicle accident (MVA) in which she was the front seat passenger. Suspicion was raised as to the presence of a retro-peritoneal bleed or hollow organ perforation upon sighting extensive thoraco-abdominal swelling and haematoma in conjunction with a tachycardic heart rhythm of 110 to 130 beats per minute. The initial chest radiograph was deemed unremarkable with normal cardio-mediastinal contours and clear lung fields. No evidence of pneumothorax or displaced rib injury was detected despite the patient complaining of slight chest discomfort on inspiration.As this woman was of child-bearing age and a radiation worker, doctors were hesitant to perform a CT scan initially, and as such intravenous fluids were hung and a period of observation undertaken in the hope that the tachycardia would subside. An ECG eight hours post MVA continued to demonstrate a tachycardic rhythm, and so it was decided to perform an abdominal ultrasound to exclude any intraperitoneal bleeding. No free fluid or solid organ lacerations were detected on the ultrasound scan. As mesenteric shearing could not be excluded by ultrasound, a CT was requested of the abdomen and pelvis. The results were again unremarkable, and the patient was observed overnight in case any pathology developed in the critical hours post trauma. Nine hours later, the patient's heart rate had dropped below 100 beats per minute, her chest sounds were cle...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Ultrasound in the diagnosis of rib fracture following blunt chest trauma: a case study

Napier

2019

Sonography

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“…Although indications for surgical intervention is determined by the surgeon, some of them include failed non-operative (Closed) management, unstable open fractures, and non-unions or malunions. (47,48) Multiple Trauma, and Other Causes Two reports were available on multiple trauma. One study in Kermanshah revealed a rate of 12.6% (25) and another study in Tehran alluded to a rate of 35%.…”

Section: Multiple Fracturesmentioning

confidence: 99%

Fatal Traffic Accidents- A Review on the Causes of Mortality in Iran

Ganji¹,

Ganji²

2018

jemds

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“…12 Witt and Bulger also showed the benefits of clinical scoring systems and early multimodal analgesia. 4 The use of guidelines and protocols with associated severity scoring systems to assist with the escalation of pain management is essential. Approximately one third (31.4%) of respondents had a protocol for analgesia in their place of work, with 81.8% of respondents stating they always or usually followed the protocol, suggesting that protocols are well utilized when present.…”

Section: Guideline Adoptionmentioning

confidence: 99%

“…The risk of mortality doubles in those above 65 years of age. 3,4 Complications include pneumonia, pulmonary effusion, acute respiratory distress syndrome, lobar collapse, and a requirement for noninvasive or invasive ventilation. [5][6][7] Currently 11 to 31% of patients with MRFs will develop pneumonia, 6,7 with odds of mortality nearly four times that of those without.…”

Section: Introductionmentioning

confidence: 99%

Analgesia of Patients with Multiple Rib Fractures in Critical Care: A Survey of Healthcare Professionals in the UK

Beard¹,

Holt²,

Snelson³

et al. 2011

Indian Journal of Critical Care Medicine

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Introduction: Good analgesia has been shown to reduce the risk of pneumonia, chronic pain, and mortality in patients with multiple rib fractures (MRFs). This survey explores the current analgesic practice in the UK, protocol use, barriers to provision, and physician preferences. Materials and methods: A web-based survey was distributed nationally to an enriched cohort of clinicians working in UK trauma units with an interest in MRF management. Results: Seventy-nine healthcare professionals responded. A third (31.4%) reported that their department had a rib fracture pain protocol, 52.9% did not, and 15.7% were unsure. Significantly more respondents reported adequate pain control when a hospital protocol was present compared to when not (χ 2 , p < 0.01). Inadequate analgesia, a poor cough, and inability to breathe deeply were the commonest complications reported by 81.4, 78.6, and 65.7%, respectively. Patient-controlled analgesia (PCA) was the most commonly used form of analgesia (38.6%) followed by thoracic epidural (TEA) (30.0%) and continuous opioid infusion (18.6%). However, TEA was the preferred method of analgesia among respondents (37.1%) followed by serratus block (21.4%), paravertebral block (17.1%), and PCA (14.3%). Discussion: There is considerable variation among physicians in their current use of analgesic modalities, with opiate-based methods predominating despite a physician preference for regional techniques. Thoracic epidurals are preferred by physicians but of limited use as a result of contraindications, time pressures, and staff skill mix. Pain control is reported to be better handled when protocols are present. Further research focusing on currently utilized regional techniques is required in order to produce a validated standardized national protocol that is informed by the current practice, the evidence base, and limitations to service provision.

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Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol

Cited by 148 publications

References 52 publications

Ultrasound in the diagnosis of rib fracture following blunt chest trauma: a case study

Ultrasound in the diagnosis of rib fracture following blunt chest trauma: a case study

Fatal Traffic Accidents- A Review on the Causes of Mortality in Iran

Analgesia of Patients with Multiple Rib Fractures in Critical Care: A Survey of Healthcare Professionals in the UK

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