Pain-associated Respiratory Failure in Chest Trauma

Abstract

T he leading cause of death in young people is trauma. Chest trauma has high associated mortality, thus diagnosis and treatment need to be addressed early on presentation. 1 The incidence of rib fractures range from 10% to 26% in traumatic thoracic injury and the number of rib fractures independently predict patients' pulmonary morbidity and mortality.2 Numerous cardiopulmonary to neurologic causes such as tamponade, hemo-pneumothorax, and cervical spine injury can be implicated ( fig. 1). Severe respiratory distress can also result from breathing-dependent pain where parenteral opioids are often insufficient in addressing the pain and associated respiratory failure.3 epidural analgesia is associated with reduction in mortality for all patients with multiple rib fractures but is underused, in part due to the potential risks of epidural hematomas. 2,4 Variables that alter the risk of bleeding including age and sex, comorbidities such as diabetes and liver cirrhosis, severity of trauma and degree of resuscitation, and anticoagulation or antiplatelet therapy must also be considered.We describe a patient under clopidogrel therapy presenting to the intensive care unit (ICU) with severe respiratory distress that improved with epidural analgesia. We provide a discussion of the risks and benefits of neuraxial analgesia in patients presenting with rib-fracture pain-related respiratory failure. Case ReportA 79-yr-old man with a history of chronic obstructive pulmonary disease, bronchiectasis, coronary artery disease postplacement of bare-metal stent several years ago, hypertension, and diabetes was transferred to our hospital shortly after motor-vehicle collision. home medications were aspirin 325 mg, clopidogrel 75 mg per day (taken morning of accident), as well as inhaled tiotropium, inhaled fluticasone/ salmeterol, albuterol, isosorbide dinitrate, metformin, and simvastatin. On arrival, the patient was hemodynamically stable with pulse oximeter saturations of 94% on a nonrebreather mask with 60% inspired oxygen concentration. Computed tomography imaging revealed second to ninth anterior right rib fractures, fourth through ninth anterior left rib fractures, and posterior 10th and 11th left rib fractures, but without flail chest nor pneumothorax. A small left pleural effusion, left lung and lingular atelectasis, and minimal ground glass opacity in the right upper lobe, and a small right-lower lobe pulmonary contusion were shown ( fig. 2). The patient received 3 l lactated Ringer's solution before arriving in our ICU. his Injury Severity Score of 24 was primarily due to rib and lung injuries (16 points), then moderate head and surface injuries (4 points each).After admission to the surgical ICU, he developed increasing pain-related respiratory distress during the day. Tylenol was administered, and hydromorphone 0.2 mg intravenously produced somnolence, but minimal improvement of respiratory effort and pain. he had an electrocardiogram unremarkable for cardiac ischemia and negative cardiac isoenzymes and brain-natriuertic ...

Effectiveness of surgical fixation for rib fractures in relation to its timing: a retrospective Japanese nationwide study

“…Furthermore, rib fractures are strongly associated with other pulmonary complications such as pneumothorax, hemothorax and pulmonary contusion [ 3 ]. Some patients, therefore, require mechanical ventilation [ 4 , 5 ].…”

A randomized control trial to compare thoracic epidural with intercostal block plus intravenous morphine infusion for postoperative analgesia in patients undergoing elective thoracotomy

“…The safety placement of continuous intercostal nerve blockade even in a coagulopathic patient has been reported. [ 24 ] Difficult thoracic spinal anatomy makes an epidural technique more difficult and more likely to be associated with complications. In this situation, ICB technique can be performed under direct vision by the surgeon before the end of the surgical procedure.…”

Thoracic and Abdominal Injuries

“…In patients with pulmonary contusions, especially in the elderly, the deleterious effects of pain are increased. Aggressive pain control applied early after the injury using multimodal analgesia appears to reduce the incidence of respiratory failure, pulmonary sepsis, and subsequent mortality [75]. In our experience, the most effective pain management technique is continuous thoracic epidural analgesia with .125-0.25 %) placed at the dermatomal level of the injury and infused at a rate of 4-8 mL/ h with careful monitoring of pain level and systemic blood pressure.…”

“…Prior to attempting epidural analgesia however, pulmonary and cardiogenic causes of respiratory failure and the various causes of coagulation abnormalities must be eliminated, while analgesia is provided by multimodal techniques (Fig. 11.13) [75]. Unfortunately concomitant spine or other injuries, and inability of the patient to consent to the procedure often preclude this treatment.…”