Fall workshop presention - Rib Fracture Management

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Management of Traumatic Rib
Fractures
Benjamin Jorgensen, MD PGY-2
University of South Dakota
Surgery Department
Importance?
Rib Fractures
• Most common injury in chest trauma
– 10% of all traumas
– 30% of significant chest trauma
• # of rib fractures correlates with severity of
injury
• Geriatric population
• Management largely conservative
Outline
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Background
Anatomy
Structural Physiology
Injuries and mechanisms
Treatments
Trimodal Distribution of Death
Rib fx correlating with Injury severity
Graeber and Nazim, 2007.
Graeber and Nazim, 2007.
Graeber and Nazim, 2007.
Graeber and Nazim, 2007.
Case study
• 80M farmer fall from ladder of tractor.
• PMH/PSH:
– Chronic Afib on Xarelto
– CABG
• Vitals: T 37 HR 110 BP 125/80 R 23 SpO2 100% 15L
Mediastinal
Injury
Intrathoracic
Injury
Intraabdominal
Injury
*Think associated internal injury with serious trauma
Associated Injuries
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Hemopneumothorax
Lung parenchyma and airways
Heart/Pericardium
Aorta
Spleen
Liver
Kidneys
Clavicles and Scapula
Spine
Head
Case (cont’d)
Case (cont’d)
Flail Segment
“Three of more adjacent ribs are each fractured in two
places, creating one floating segment comprised of
several rib sections and the soft tissues between
them.”
Consequences of Rib Fractures
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Pain
Respiratory Failure
Pneumonia
Retained hemothorax
Empyema
Deformity
Non-union
General Management Issues
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Monitoring
Pain management
Respiratory therapy
Fluid management
DVT prophylaxis
Nutrition for wound healing
**Multidisciplinary approach associated with shorter
ICU and hospital stay, and lower mortality.
Outpatient Management
• Clinical exam is going to be most important
determinant of disposition.
• Patients may safely be managed as an
outpatient if able to clear secretions and
cough with adequate pain control
– ~20% return to the ED, most commonly due to
inadequate analgesia
• Followup chest X ray within 2 weeks.
Indications for Transfer or ICU
Observation
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Age >65
>3 fractures
Hypoxia
Abnormal CXR
High energy mechanism (pulmonary
contusion)
• Observation of pneumothorax
• Other comorbidities/injuries
Respiratory Care
• Volume Expansion
– EZ Pap
– Incentive Spirometry
– Acapella
– Cough and deep breath
• Monitor for respiratory fatigue
– Intubation as needed
– Flail chest increased risk.
• Be cautious with IVF!
Pain Management
Difficult to control with multiple rib fractures
leading to:
– Decreased pulmonary function
– Increased hospital length of stay
– Increased health care expenditures
**Multimodality pain approach
Pain Management
**Physical Exam  COUGH assessment
Pain Management
**Goal is adequate pain relief for airway clearance.
• PCA (Level 2 evidence)
– Survival advantage in elderly pts with blunt trauma
• IV NSAID
– Decreased narcotic use
– May prevent bone healing
– Precaution with renal imparement
Pain Management
• Regional analgesia
– Thoracic epidural analgesia or Thoracic
paravertebral infusion
• Technically demanding
• Significant patient cooperation (feasibility in ICU?)
– Continuous Bupivicaine (i.e. On-Q pump)
• No comparative studies to epidurals in rib fx, but
superior in thoracotomies
• Must monitor cardiac depression (i.e. AV block,
ventricular arrythmias)
– Lidoderm Patches
Operative Chest Wall Stabilization
Case (cont’d)
• Transferred to ICU from ED
• Pain management with PCA and lidoderm
patches  pain difficult to control.
• Requiring BIPAP.
• HD #2, decision made to perform rib plating.
Operative Chest Wall Stabilization
• Indications:
– Flail chest
– Symptomatic fractures of 3 or more consecutive
ribs
– Severe chest wall deformity with or without pulm
herniation
– Symptomatic Nonunion
– Unable to be wean from ventilator
Operative Chest Wall Stabilization
Studies suggest:
– better pain control
– earlier return to activity
– potentially improved quality of life and pulmonary
function tests at 6 month follow up.
Case (cont’d)
• Pain significantly improved.
• Resp Insufficiency secondary to contusions
and retained hemothorax
• Transferred to floor POD #14
Summary
• # of rib fractures correlates with severity of
injury  think associated injuries.
• Be wary of geriatric patient
• Cough assessment with physical exam
• Multidisciplinary approach to management
• Multimodality pain approach
• Operative fixation for select patients
Questions?
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