Vital capacity as a predictor of outcome in elderly patients with rib fractures

BACKGROUND: This study tests the relationships between early bedside vital capacity (VC) measurement and morbidity, mortality, and resource consumption in geriatric blunt chest trauma patients with rib fractures. METHODS: This was a retrospective study examining all patients > or = 65 years old with rib fractures who had a VC measured within 48 hours of their emergency department evaluation. Outcome variables included pulmonary complications, death from pulmonary complications, hospital length of stay (LOS), intensive care unit length of stay (ICU LOS), and discharge disposition. RESULTS: Thirty-eight patients met the study criteria. The mean age was 80.2 (+/-7.4) years, the mean number of rib fractures was 3.6 (+/-1.6), and the mean ISS was 6.9 (+/-4.7). VC and the percentage of the predicted vital capacity (pVC) were both inversely correlated with LOS (p = 0.0076 and p = 0.0172, respectively). Linear regression analysis suggested that patients with a VC < 1.4 L or < 55% of their pVC had a LOS > 3 days. Mean VC was 36% higher in patients who were discharged home versus those discharged to an extended care facility (ECF; p = 0.025). There was a trend toward significance when comparing VC to ICU LOS (p = 0.079), but none in predicting pulmonary complications (p = 0.3299). No correlations between VC and mortality can be drawn given the single death in the cohort. CONCLUSIONS: Bedside VC is a simple measurement which could predict LOS in elderly patients with rib fractures and may identify those patients requiring ECF upon discharge. Further prospective study may highlight the utility of emergency room VC in determining the disposition of these patients.     

Lidocaine patches reduce pain in trauma patients with rib fractures

Rib fracture pain is notoriously difficult to manage. The lidocaine patch is effective in other pain scenarios with an excellent safety profile. This study assesses the efficacy of lidocaine patches for treating rib fracture pain. A prospectively gathered cohort of patients with rib fracture was retrospectively analyzed for use of lidocaine patches. Patients treated with lidocaine patches were matched to control subjects treated without patches. Subjective pain reports and narcotic use before and after patch placement, or equivalent time points for control subjects, were gathered from the chart. All patients underwent long-term follow-up, including a McGill Pain Questionnaire (MPQ). Twenty-nine patients with lidocaine patches (LP) and 29 matched control subjects (C) were analyzed. During the 24 hours before patch placement, pain scores and narcotic use were similar (LP 5.3, C 4.6, P = 0.19 and LP 51, C 32 mg morphine, P = 0.17). In the 24 hours after patch placement, LP patients had a greater decrease in pain scores (LP 1.2, C 0.0, P = 0.01) with no change in narcotic use (LP -8.4, C 0.5-mg change in morphine, P = 0.25). At 60 days, LP patients had a lower MPQ pain score (LP 7.7, C 12.2, P < 0.01), although only one patient was still using a patch. There was no difference in time to return to baseline activity (LP 73, C 105 days, P = 0.16) and no adverse events. Lidocaine patches are a safe, effective adjunct for rib fracture pain. Lidocaine patches resulted in a sustained reduction in pain, outlasting the duration of therapy.     

Incidence and outcomes of major trauma patients with thoracic injuries and rib fractures in Aotearoa New Zealand

IntroductionThoracic trauma represents a significant burden of disease in Aotearoa, New Zealand (AoNZ). To date, no study has examined the incidence or outcomes of patients suffering major thoracic trauma, or major trauma and rib fractures in AoNZ.MethodsA 6 year retrospective study of all major trauma (Injury Severity Score >12) patients in AoNZ was performed. The National Trauma Registry was searched to identify patients. The National Minimum Data Set was searched for all ICD-10 codes associated with surgical stabilisation of rib fractures (SSRF). Poisson regression was used to determine the change in incidence rate over the study period adjusted for age with the logarithm of population size as the offset variable. The incidence rate ratios (IRR) with 95% confidence intervals (CI) were reported.Results12,218 patients sustained major trauma. 7,059 (57.8%) of these patients sustained thoracic injuries. Of these patients, 5,585 (79.1%) sustained rib fractures, and 180 (3.2%) proceeded to SSRF. A flail segment was observed in 16% of patients with rib fractures. Transport was the mechanism of injury in 53% of patients. During the study the incidence (cases per 100,000 people per year) of major trauma increased from 39.5 to 49.3 (IRR 1.05, 95%CI 1.04 to 1.07, <0.001), the incidence of thoracic injuries from 21.3 to 28.7 (1.07, 95% CI 1.05 to 1.08, <0.001) and the incidence of rib fractures from 16.0 to 22.9 (1.08, 95% CI 1.06 to 1.09, <0.001). SSRF was performed in 3.2% of patients with rib fractures and increased from 0.2 to 0.8 cases per 100,000 people per year (1.27, 95% CI 1.15 to 1.41, <0.001) during the study.ConclusionThis study reports the incidence of major trauma patients with thoracic injury, major trauma patients with rib fractures and the incidence of SSRF in AoNZ. Transport related injuries are the predominant mechanism of injury. The incidence of SSRF was low across AoNZ. To improve the quality of care in AoNZ for major trauma patients with rib fractures, consideration should be made to create national guidelines and robust referral pathways to specialist centres that provide multidisciplinary care including performing SSRF.     

Outcomes after rib fractures in geriatric blunt trauma patients

Introduction

Rib fractures after blunt trauma contribute substantially to morbidity and mortality in the elderly.

Long term outcomes following rib fracture fixation in patients with major chest trauma

BackgroundSevere chest injuries are associated with significant morbidity and mortality. Surgical rib fixation has become a more commonplace procedure to improve chest wall mechanics, pain, and function. The aim of this study was to characterise the epidemiology and long-term functional outcomes of chest trauma patients who underwent rib fixation in a major trauma centre (MTC).MethodologyThis was a retrospective review (2014–19) of all adult patients with significant chest injury who had rib fixation surgery following blunt trauma to the chest. The primary outcome was functional recovery after hospital discharge, and secondary outcomes included length of intensive care unit (ICU) and hospital stay, maximum organ support, tracheostomy insertion, ventilator days.Results60 patients underwent rib fixation. Patients were mainly male (82%) with median age 52 (range 24–83) years, injury severity score (ISS) of 29 (21–38), 10 (4–19) broken ribs, and flail segment in 90% of patients. Forty-six patients (77%) had a good outcome (GOSE grade 6–8). Patients in the poor outcome group (23%; GOSE 1–5) tended to be older [55 (39–83) years vs. 51 (24–78); p = 0.05] and had longer length of hospital stay [42 (19–82) days vs. 24 (7–90); p<0.01]. Injury severity, rate of mechanical ventilation or organ dysfunction did not affect long term outcome. Nineteen patients (32%) were not mechanically ventilated.ConclusionsRib fixation was associated with good long-term outcomes in severely injured patients. Age was the only predictor of long-term outcome. The results suggest that rib fixation be considered in patients with severe chest injuries and may also benefit those who are not mechanically ventilated but are at risk of deterioration.     

Dementia as a predictor of mortality in adult trauma patients

Background

The specific contribution of dementia towards mortality in trauma patients is not well defined. The purpose of the study was to evaluate dementia as a predictor of mortality in trauma patients when compared to case-matched controls.

Frailty as a predictor of fractures among community-dwelling older people: A systematic review and meta-analysis

PurposeTo identify prospective studies examining associations between frailty and fractures and to combine the risk measures to synthesize pooled evidence on frailty as a predictor of fractures among community-dwelling older people.MethodsA systematic literature search was conducted using five databases: Embase, MEDLINE, CINAHL Plus, PsycINFO, and the Cochrane Library for prospective studies on associations between frailty and fracture risk published from 2000 to August 2015 without language restriction. Odds ratios (OR) and hazard ratios (HR) extracted from the studies or calculated from available data were combined to synthesize pooled effect measures using random-effects or fixed-effects models. Heterogeneity, methodological quality, and publication bias were assessed. Meta-regression analyses were performed to explore the cause of high heterogeneity.ResultsOf 1305 studies identified, six studies involving 96,564 older people in the community were included in this review. Frailty and prefrailty were significantly associated with future fractures among five studies with OR (pooled OR = 1.70, 95% confidence interval (95% CI) = 1.34–2.15, p < 0.0001; pooled OR = 1.31, 95% CI = 1.18–1.46, p < 0.00001, respectively) and four studies with HR (pooled HR = 1.57, 95% CI = 1.31–1.89, p < 0.00001; pooled HR = 1.30, 95% CI = 1.12–1.51, p = 0.0006, respectively). High heterogeneity was observed among five studies with OR of frailty (I² = 66%). The studies from the United States were found to have a higher fracture risk than from those from other countries in a meta-regression model (regression coefficient = 0.39, p = 0.04). No evidence of publication bias was identified.ConclusionsThis systematic review and meta-analysis showed evidence that frailty and prefrailty are significant predictors of fractures among community-dwelling older people. Treating frailty may potentially lead to lowering fracture risks.     

Management and outcomes of rib fractures in patients with isolated blunt thoracic trauma: Results of the Aotearoa New Zealand RiBZ study

AimRib fractures are common and associated with significant morbidity and mortality. There is limited literature on patient care and outcomes in Aotearoa New Zealand (AoNZ). The aim of this study is to describe key clinical outcomes and management interventions for patients with rib fractures across AoNZ.MethodsA national prospective multicenter observational cohort study was performed. Patients admitted between 1 December 2020 and 28 February 2021 with one or more radiologically proven rib fractures and an Abbreviated Injury Score of the head or abdomen of less than 3 were included. The primary outcomes of interest were the rates of thirty-day pneumonia, re-presentation and mortality. The secondary outcomes of interest were rate of surgical stabilisation of rib fractures (SSRF) and pain management of patients with rib fractures. Binomial logistic regression was performed for the primary outcomes and funnel plots were created of the inter-hospital variation in pneumonia.ResultsFourteen AoNZ hospitals and 407 patients were included. Mean age was 57.4 (SD 18.7), 28% were female, 15% Māori and 85% non-Māori. The median number of rib fractures was 4. The rate of pneumonia, re-presentation and mortality was 11%, 8% and 2%, respectively. Logistic regression found the odds of pneumonia increased with each additional rib fracture (OR 1.15 95% CI 1.05–1.25) and the odds of re-presentation increased with age (OR 1.028 95% CI 1.005–1.051) and Māori ethnicity (OR 2.754 95% CI 1.077–7.045). The funnel plot of inter-hospital variation in pneumonia rate adjusted for clinically plausible variables found no centre lay outside the 95% confidence interval. SSRF was performed in 2% of patients. 58% of patients had a pain team review and 23% a regional block.ConclusionThis study describes clinical outcomes for patients with isolated rib fractures from multiple hospitals in AoNZ. A moderate pneumonia rate of 11% was found which is likely amendable to reduction with quality improvement initiatives. Consideration should be given to further resource and improve the access to SSRF and regional analgesia given the low utilization found across AoNZ. A higher re-presentation rate in Māori and elderly patients was found which needs further investigation.     

Clinical management of blunt trauma patients with unilateral rib fractures: A randomized trial

Optimal pain management is essential in blunt trauma patients sustaining significant chest trauma. The purpose of this randomized prospective trial was to measure the difference in pulmonary function in nonintubated patients with unilateral multiple rib fractures receiving two modalities of pain relief: systemic narcotic medications alone or local anesthetics given by intrapleural catheter (IPCs). Forty-two patients were randomized to receive systemic narcotic medications or IPCs for pain control. The patients with IPCs statistically had more compromised pulmonary function as measured by forced vital capacity (FVC) on admission; however, they tended toward a greater objective improvement of FVC on discharge. When analyzing a cohort of severely impaired patients (initial FVC<20%), half of the systemic medication patients compared to only 10% of the IPC group failed and required another mode of therapy. Catheter complications were minor and did not contribute to overall morbidity. The IPC patients had fewer failures than the systemic medication patients.

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Resumen El manejo óptimo de dolor es un componente esencial en los pacientes con trauma torácico cerrado. El propósito de este ensayo prospectivo y randomizado fue determinar diferencias en la función pulmonar entre pacientes con fracturas múltiples unilaterales no intubados y recibiendo dos modalidades de control del dolor: medicación narcótica sistémica solamente o anestésicos locales por catéter intrapleural. Cuarenta y dos pacientes fueron randomizados para recibir medicacións sistémica o anestésicos locales por catéter intrapleural. Los pacientes con el catéter demostraban estadísticamente mayor compromiso de su función pulmonar, según medición de la capacidad vital forzada (FVC) en el momento de la admisión; sin embargo, mostraron una tendencia hacia una mayor mejoría objetiva de la FVC en el momento de su egreso. Al analizar una cohorte de los pacientes más severamente afectados (FVC<20%), la mitad de los tratados mediante narcóticos sistémicos comparado con sólo 10% del grupo del catéter fallaron y requirieron una modalida terapéutica diferente. Las complicaciones de catéter fueron menores y no contribuyeron a la morbilidad global. Los pacientes con catéter exhibieron menos fallas terapéuticas que los tratados con medicación sistémica.

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Résumé Il est essentiel de bien traiter la douleur post traumatique du thorax. Le but de cette étude randomisée a été mesurer la fonction pulmonaire des patients non intubés avec de multiples fractures costales recevant deux sortes d'antalgiques, des narcotiques par voie systématique ou une anesthésie locale par cathéter intra pleural (CIP). Quarante deux patients on été randomisées pour recevoir l'une ou l'autre des modalités thérapeutiques. Les patients dans le groupe CIP avaient une capacité vitale totale diminuée par rapport aux autres á l'admission. Leur CIP s'améliorait davantage à la sortie. Lorsqu'un groupe de patients plus sévèrement atteints (CIP<20%) était analysés, la moitié des patients dans le groupe traité par voie systématique était soulagé alors que 90% des patients traités par CIP ont eu de bons résultats. Les complications en rapport avec le cathéter étaient mineures et n'ont pas influencé les résultats. Les patients avec un CIP ont mieux répondu au traitement.

     

Elderly trauma patients with rib fractures are at greater risk of death and pneumonia

BACKGROUND: The purpose of this study was to show that elderly patients admitted with rib fractures after blunt trauma have increased mortality. METHODS: Demographic, injury severity, and outcome data on a cohort of consecutive adult trauma admissions with rib fractures to a tertiary care trauma center from April 1, 1993, to March 31, 2000, were extracted from our trauma registry. RESULTS: Among 4,325 blunt trauma admissions, there were 405 (9.4%) patients with rib fractures; 113 were aged > or = 65. Injuries were severe, with Injury Severity Score (ISS) > or = 16 in 54.8% of cases, a mean hospital stay of 26.8 +/- 43.7 days, and 28.6% of patients requiring mechanical ventilation. Mortality (19.5% vs. 9.3%; p < 0.05), presence of comorbidity (61.1% vs. 8.6%; p < 0.0001), and falls (14.6% vs. 0.7%; p < 0.0001) were significantly higher in patients aged > or = 65 despite significantly lower ISS (p = 0.031), higher Glasgow Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001). After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity, and multiple rib fractures, patients aged > or = 65 had five times the odds of dying when compared with those < 65 years old. CONCLUSION: Despite lower indices of injury severity, even after taking account of comorbidities, mortality was significantly increased in elderly patients admitted to a trauma center with rib fractures.     

Frailty defined by 19 items as a predictor of short-term functional recovery in patients with hip fracture

IntroductionMany hip fracture patients have decreased functional status inhibiting recovery to pre-fracture functional status. The prevalence of frailty in patients with hip fracture is high, but little is known how frailty is associated with functional recovery. The aim of this study was to determine whether frailty can predict functional recovery and clinical outcomes during the acute phase in hip fracture.Patients and MethodsThis study was retrospective observational study from two acute hospitals. Participants were recruited from hip fracture patients who underwent surgery. The main exposure was frailty defined using 19-item modified Frailty Index (mFI). The main outcome was functional recovery, evaluated by postoperative efficiency on the motor-Functional Independence Measure (FIM) score. Secondary outcomes included postoperative complication and discharge disposition. Multiple logistic regression analyses were performed using each outcome as a dependent variable and mFI as an independent variable.ResultsSample included 274 patients (mean age 83.7 ± 7.4 years, female 80.7%). Patients with higher mFI exhibited lower functional recovery, defined by efficiency on the motor-FIM score, and tended to run into complications and not return home (P < .001). In multiple logistic regression analyses, higher mFI was significantly associated with increased likelihood of lower functional recovery (odds ratio [OR], 1.60; 95% CI, 1.32–1.93; P < .001), occurrence of postoperative complication (OR, 1.32; 95% CI, 1.13–1.54; P < .001) and not returning home (OR, 1.77; 95% CI, 1.38–2.26; P < .001).ConclusionsFrailty defined by 19-item mFI can predict short-term functional recovery during acute phase following hip fracture. Frailty is also associated with postoperative complication and discharge disposition.     

Impact of rib fixation on quality of life after major trauma with multiple rib fractures

Introduction

Multiple rib fractures have been shown to reduce quality of life both in the short and long term. Treatment of rib fractures with operative fixation reduces ventilator requirements, intensive care unit stay, and pulmonary complications in flail chest patients but has not been shown to improve quality of life in comparative studies to date. We therefore wanted to analyse a large cohort of multiple fractured rib trauma patients to see if rib fixation improved their quality of life.

Significance of rib fractures in simple and multiple trauma]

In a retrospect study we evaluated the clinical impact of traumatic rib fractures. Our series included 96 patients treated between 1986 and 1988. Haemato- and/or pneumothorax corresponded closely to the number of fractured ribs. There was a highly significant association (p less than 0.001) between the number of fractured ribs and polytrauma. The leading cause of injuries was a traffic accident.     

The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children

BACKGROUND: Rib fractures have a strong association with nonaccidental trauma (NAT) and severe trauma. The purposes of this study were to evaluate rib fractures in children to determine (1) the positive predictive value of a rib fracture in defining NAT and (2) the frequency of rib fractures as the only skeletal manifestation of NAT. METHODS: We reviewed the medical records and imaging of all children with rib fractures over a 6-year period. NAT was determined by the Child Advocacy and Protection team. RESULTS: In children younger than 3 years of age, the positive predictive value (PPV) of a rib fracture as an indicator of NAT was 95%. The positive predictive value increased to 100% once historical and clinical circumstance excluded all other causes for rib fractures. CONCLUSION: In this study, rib fracture(s) were the only skeletal manifestation of NAT in 29% of the children.     

Proteinuria as a predictor of renal dysfunction in trauma patients receiving intravenous contrast

Trauma patients have unknown comorbidities, multiple injuries, and incomplete laboratory testing, yet require contrast-enhanced imaging to identify potentially life-threatening problems. Our goal was to characterize contrast-induced nephropathy (CIN) in this population. We retrospectively reviewed characteristics of 402 patients who presented to a Level II trauma center and received contrast-enhanced imaging. CIN was defined as creatinine rise of 0.5 mg/dL or greater or 25 per cent or greater from baseline within 48 hours. CIN occurred in 7.7 per cent and four patients required hemodialysis. Patients with CIN were older, had lower admission hemoglobin, higher Injury Severity Score, and received more blood products. Factors that predicted CIN included: male sex, age older than 46 years, body mass index less than 27 kg/m2, glomerular filtration rate less than 109 mL/min/1.73 m2, hemoglobin less than 12 mg/dL, hematocrit less than 36 per cent, proteinuria, 2 units or more of fresh-frozen plasma in 48 hours, and alcohol use. Odds ratio for developing CIN with two, five, or six of these factors was 3.39, 6.54, and 8.38, respectively. A match-controlled analysis for Injury Severity Score and age in patients with CIN versus non-CIN patients revealed the strongest predictor of CIN was proteinuria (relative risk, 2.5; confidence interval, 1.1 to 5.8). Although it is difficult to truly differentiate CIN from renal dysfunction related to injury severity in trauma patients, proteinuria may be an important factor in identifying nephropathy in this population.     

Intrapleural catheter analgesia in patients with multiple rib fractures

Patients with multiple rib fractures often suffer from severe pain that impairs their respiratory performance. The effect of interpleural administration of bupivacaine (20 ml 0.25% every 4 h) for pain management was evaluated in ten patients. The initial interpleural injection resulted in significant pain relief and improvement of arterial oxygen tension. Two patients needed additional i.v. injections of opioids (piritramide 15-22.5 mg/24 h). In one patient a small asymptomatic pneumothorax was observed following placement of the catheter, which resolved spontaneously. No other complications were reported. In an intraindividual comparison, bupivacaine alone and bupivacaine plus epinephrine 1:200,000 were compared with regard to pharmacokinetics of bupivacaine, analgesic effect, side effects, and respiratory performance. The addition of epinephrine yielded only minor advantages from a pharmacokinetic point of view (median peak concentration of bupivacaine 1.8 micrograms/ml vs 2.0 micrograms/ml for bupivacaine alone). The quality and duration of analgesia and the effects on respiration were not influenced by epinephrine. The heart rate was significantly higher and the blood pressure significantly lower when epinephrine was added to the solution. Nevertheless, these differences were too small to be of clinical importance. Even though maximum total plasma concentrations of bupivacaine above 2 micrograms/ml were found in some patients, there were no signs of CNS toxicity, most probably because of the increased protein binding of bupivacaine following trauma. Accordingly, the maximum free plasma concentrations in all patients were below the threshold level of 0.24 micron/ml. We therefore conclude tht interpleural administration of bupivacaine could be a valuable means of pain relief in patients with multiple rib fractures, providing no severe pulmonary contusions or concomitant injuries are present.