Older Adults With Isolated Rib Fractures Do Not Require Routine Intensive Care Unit Admission

Abstract

Background: Older adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidencebased guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care. Materials and methods: We analyzed patients !50 y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs. Results: Among 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry <1 L (OR 4.72, 95% CI 2.14-10.45); use of a walker (OR 2.86, 95% CI 1.29-6.34); increased chest Abbreviated Injury Scale score (AIS 3

Association of Hospital-Level Intensive Care Unit Use and Outcomes in Older Patients With Isolated Rib Fractures

“…11 None of these studies specifically evaluated patients with isolated rib fractures. Among patients at our center, we observed that only 25% of older patients with isolated rib fractures experienced an intervention or event suggestive of requiring ICU-level care, 12 so consistent with the large NNT we estimated, any putative benefits of ICU admission may apply to a relatively small subpopulation of all older patients with isolated rib fractures. Several studies have retrospectively identified patient and injury characteristics that increase the likelihood of poor outcomes, [13][14][15][16] although few have focused on older patients with isolated rib fractures.…”

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

“…Although it is now well recognised that patients with blunt chest wall trauma are at risk of developing complications, to date no universally accepted guidelines exist to assist in the recognition of these high-risk populations 1 2. Many EDs globally have adopted clinical protocols that routinely advise admission to a critical care setting where possible for elderly patients with increasing numbers of rib fractures 3 4. Studies have also considered whether such patients should be considered for immediate transfer to a specialist trauma unit for the appropriate level of care to be provided 5–7.…”

Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society

“…These studies were retrospective with different definitions. Some studies included older patients, [11][12][13] while other studies included all patients. There was little discussion regarding the predetermined critical outcomes.…”

“…Although we cannot offer a recommendation on ICU admission for all patients older than 65 years, ICU admission should be considered in patients who also have frailty or deconditioning, hypoxemia (room air O 2 saturation <92%), IS <1 L, more severe chest injuries (chest AIS score, >3), use of a walker, and smoking. 11,13,[60][61][62] Incentive spirometry and effective pain control are mainstays of management. Poor use of IS (<1 L) or presence of tube thoracostomy should prompt close monitoring.…”