Top

Current Anesthesiology Reports

Published in:

01-03-2020 | Thoracic Trauma | Anesthesia for Trauma (TE Grissom, Section Editor)

Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries

Authors: Michelle Kim, James E. Moore

Published in: Current Anesthesiology Reports | Issue 1/2020

Abstract

Purpose of Review

This article provides an overview of the common and important chest injuries that the anesthesiologist may encounter in patients following trauma including blunt injury, pneumothorax, hemothorax, blunt aortic injury, and blunt cardiac injury.

Recent Findings

Rib fractures are frequently associated with chest injury and are associated with significant pain and other complications. Regional anesthesia techniques combined with a multimodal analgesic strategy can improve patient outcomes and reduce complications. There is increasing evidence for paravertebral blocks for this indication, and the myofascial plane blocks are a popular emerging technique. Recent changes to recommended management of tension pneumothorax are also described.

Summary

Chest trauma is commonly encountered, and anesthesiologists have the potential to significantly improve morbidity and mortality in this group of patients.

Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138(4):717–23; discussion 23-5. https://doi.org/10.1016/j.surg.2005.07.022.CrossRefPubMed

O'Kelly E, Garry B. Continuous pain relief for multiple fractured ribs. Br J Anaesth. 1981;53(9):989–91. https://doi.org/10.1093/bja/53.9.989.CrossRefPubMed

Mackersie RC, Karagianes TG, Hoyt DB, Davis JW. Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures. J Trauma. 1991;31(4):443–9 discussion 9-51.CrossRef

Moon MR, Luchette FA, Gibson SW, Crews J, Sudarshan G, Hurst JM, et al. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg. 1999;229(5):684–91; discussion 91-2. https://doi.org/10.1097/00000658-199905000-00011.CrossRefPubMedPubMedCentral

Ravalia A, Suresh D. I.V. alfentanil analgesia for physiotherapy following rib fractures. Br J Anaesth. 1990;64(6):746–8. https://doi.org/10.1093/bja/64.6.746.CrossRefPubMed

Solak O, Oz G, Kokulu S, Solak O, Dogan G, Esme H, et al. The effectiveness of transdermal opioid in the management multiple rib fractures: randomized clinical trial. Balkan Med J. 2013;30(3):277–81. https://doi.org/10.5152/balkanmedj.2013.8191.CrossRefPubMedPubMedCentral

Fulda GJ, Giberson F, Fagraeus L. A prospective randomized trial of nebulized morphine compared with patient-controlled analgesia morphine in the management of acute thoracic pain. J Trauma. 2005;59(2):383–8; discussion 9-90. https://doi.org/10.1097/01.ta.0000179452.70520.1b.CrossRefPubMed

Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, et al. Opioid complications and side effects. Pain Physician. 2008;11(2 Suppl):S105–20.PubMed

• Bayouth L, Safcsak K, Cheatham ML, Smith CP, Birrer KL, Promes JT. Early intravenous ibuprofen decreases narcotic requirement and length of stay after traumatic rib fracture. Am Surg. 2013;79(11):1207–12 Evidence for NSAID use in rib fractures.PubMed

10.

• Yang Y, Young JB, Schermer CR, Utter GH. Use of ketorolac is associated with decreased pneumonia following rib fractures. Am J Surg. 2014;207(4):566–72. https://doi.org/10.1016/j.amjsurg.2013.05.011Evidence for reduced complications if NSAIDs used following rib fractures.CrossRefPubMed

11.

• Galvagno SM Jr, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, et al. Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936–51. https://doi.org/10.1097/TA.0000000000001209Recent combined society guidance on blunt trauma analgesia.CrossRefPubMed

12.

Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury. 2012;43(1):8–17. https://doi.org/10.1016/j.injury.2011.01.004.CrossRefPubMed

13.

Bergeron E, Lavoie A, Clas D, Moore L, Ratte S, Tetreault S, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478–85. https://doi.org/10.1097/01.TA.0000037095.83469.4C.CrossRefPubMed

14.

Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery. 2004;136(2):426–30. https://doi.org/10.1016/j.surg.2004.05.019.CrossRefPubMed

15.

Simon BJ, Cushman J, Barraco R, Lane V, Luchette FA, Miglietta M, et al. Pain management guidelines for blunt thoracic trauma. J Trauma. 2005;59(5):1256–67. https://doi.org/10.1097/01.ta.0000178063.77946.f5.CrossRefPubMed

16.

Carrier FM, Turgeon AF, Nicole PC, Trepanier CA, Fergusson DA, Thauvette D, et al. Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth. 2009;56(3):230–42. https://doi.org/10.1007/s12630-009-9052-7.CrossRefPubMed

17.

• Duch P, Moller MH. Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials. Acta Anaesthesiol Scand. 2015;59(6):698–709. https://doi.org/10.1111/aas.12475Recent systematic review which questions the role of thoracic epidurals.CrossRefPubMed

18.

• Peek J, Smeeing DPJ, Hietbrink F, Houwert RM, Marsman M, de Jong MB. Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2019;45(4):597–622. doi:https://doi.org/10.1007/s00068-018-0918-7. Review suggesting good analgesia with thoracic epidurals, but lack of improvement in other important endpoints.CrossRefPubMed

19.

Zaw AA, Murry J, Hoang D, Chen K, Louy C, Bloom MB, et al. Epidural analgesia after rib fractures. Am Surg. 2015;81(10):950–4.PubMed

20.

• Malekpour M, Hashmi A, Dove J, Torres D, Wild J. Analgesic choice in management of rib fractures: paravertebral block or epidural analgesia? Anesth Analg. 2017;124(6):1906–11. https://doi.org/10.1213/ANE.0000000000002113Suggests equivalence between epidural & paravertebral catheters.CrossRefPubMed

21.

• McKendy KM, Lee LF, Boulva K, Deckelbaum DL, Mulder DS, Razek TS, et al. Epidural analgesia for traumatic rib fractures is associated with worse outcomes: a matched analysis. J Surg Res. 2017;214:117–23. https://doi.org/10.1016/j.jss.2017.02.057Cohort study suggesting poorer outcomes in patients with epidural management following chest trauma.CrossRefPubMed

22.

Gilbert J, Hultman J. Thoracic paravertebral block: a method of pain control. Acta Anaesthesiol Scand. 1989;33(2):142–5. https://doi.org/10.1111/j.1399-6576.1989.tb02877.x.CrossRefPubMed

23.

McKnight CK, Marshall M. Monoplatythela and paravertebral block. Anaesthesia. 1984;39(11):1147. https://doi.org/10.1111/j.1365-2044.1984.tb08953.x.CrossRefPubMed

24.

Williamson S, Kumar CM. Paravertebral block in head injured patient with chest trauma. Anaesthesia. 1997;52(3):284–5.PubMed

25.

Cheema SP, Ilsley D, Richardson J, Sabanathan S. A thermographic study of paravertebral analgesia. Anaesthesia. 1995;50(2):118–21. https://doi.org/10.1111/j.1365-2044.1995.tb15092.x.CrossRefPubMed

26.

Karmakar MK, Chui PT, Joynt GM, Ho AM. Thoracic paravertebral block for management of pain associated with multiple fractured ribs in patients with concomitant lumbar spinal trauma. Reg Anesth Pain Med. 2001;26(2):169–73. https://doi.org/10.1053/rapm.2001.21086.CrossRefPubMed

27.

Ho AM, Karmakar MK, Critchley LA. Acute pain management of patients with multiple fractured ribs: a focus on regional techniques. Curr Opin Crit Care. 2011;17(4):323–7. https://doi.org/10.1097/MCC.0b013e328348bf6f.CrossRefPubMed

28.

Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001;95(3):771–80. https://doi.org/10.1097/00000542-200109000-00033.CrossRefPubMed

29.

Richardson J, Lonnqvist PA. Thoracic paravertebral block. Br J Anaesth. 1998;81(2):230–8. https://doi.org/10.1093/bja/81.2.230.CrossRefPubMed

30.

Mohta M, Verma P, Saxena AK, Sethi AK, Tyagi A, Girotra G. Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs--a pilot study. J Trauma. 2009;66(4):1096–101. https://doi.org/10.1097/TA.0b013e318166d76d.CrossRefPubMed

31.

• Yeying G, Liyong Y, Yuebo C, Yu Z, Guangao Y, Weihu M, et al. Thoracic paravertebral block versus intravenous patient-controlled analgesia for pain treatment in patients with multiple rib fractures. J Int Med Res. 2017;45(6):2085–91. https://doi.org/10.1177/0300060517710068Randomized trial suggesting improved ventilatory outcomes and lung mechanics in patients managed with paravertebral block.CrossRefPubMedPubMedCentral

32.

Lonnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia. 1995;50(9):813–5. https://doi.org/10.1111/j.1365-2044.1995.tb06148.x.CrossRefPubMed

33.

Shanti CM, Carlin AM, Tyburski JG. Incidence of pneumothorax from intercostal nerve block for analgesia in rib fractures. J Trauma. 2001;51(3):536–9. https://doi.org/10.1097/00005373-200109000-00019.CrossRefPubMed

34.

Truitt MS, Murry J, Amos J, Lorenzo M, Mangram A, Dunn E, et al. Continuous intercostal nerve blockade for rib fractures: ready for primetime? J Trauma. 2011;71(6):1548–52; discussion 52. https://doi.org/10.1097/TA.0b013e31823c96e0.CrossRefPubMed

35.

Rose P, Ramlogan R, Sullivan T, Lui A. Serratus anterior plane blocks provide opioid-sparing analgesia in patients with isolated posterior rib fractures: a case series. Can J Anaesth. 2019;66(10):1263–4. https://doi.org/10.1007/s12630-019-01431-7.CrossRefPubMed

36.

Southgate SJ, Herbst MK. Ultrasound guided serratus anterior blocks. Treasure Island: StatPearls; 2019.

37.

Kunhabdulla NP, Agarwal A, Gaur A, Gautam SK, Gupta R, Agarwal A. Serratus anterior plane block for multiple rib fractures. Pain Phys. 2014;17(5):E651–3.

38.

Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector Spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621–7. https://doi.org/10.1097/AAP.0000000000000451.CrossRefPubMed

39.

Klesius L, Schroeder K. Effective analgesia with bilateral erector spinae plane catheters for a patient with traumatic rib and spine fractures. Case Rep Anesthesiol. 2019;2019:9159878. https://doi.org/10.1155/2019/9159878.CrossRefPubMedPubMedCentral

40.

Luftig J, Mantuani D, Herring AA, Dixon B, Clattenburg E, Nagdev A. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med. 2018;36(8):1391–6. https://doi.org/10.1016/j.ajem.2017.12.060.CrossRefPubMed

41.

Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth. 2017;118(3):474–5. https://doi.org/10.1093/bja/aex013.CrossRefPubMed

42.

• Adhikary SD, Liu WM, Fuller E, Cruz-Eng H, Chin KJ. The effect of erector spinae plane block on respiratory and analgesic outcomes in multiple rib fractures: a retrospective cohort study. Anaesthesia. 2019;74(5):585–93. https://doi.org/10.1111/anae.14579Retrospective cohort study suggesting improved incentive spirometry volumes and pain scores with erector spinae block.CrossRefPubMed

43.

Bemelman M, Poeze M, Blokhuis TJ, Leenen LP. Historic overview of treatment techniques for rib fractures and flail chest. Eur J Trauma Emerg Surg. 2010;36(5):407–15. https://doi.org/10.1007/s00068-010-0046-5.CrossRefPubMedPubMedCentral

44.

Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005;4(6):583–7. https://doi.org/10.1510/icvts.2005.111807.CrossRefPubMed

45.

Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013;216(5):924–32. https://doi.org/10.1016/j.jamcollsurg.2012.12.024.CrossRefPubMed

46.

• Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, et al. Operative fixation of rib fractures after blunt trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82(3):618–26. https://doi.org/10.1097/TA.0000000000001350Recent society guidance on the role of operative fixation of rib fractures.CrossRefPubMed

47.

• Pieracci FM, Coleman J, Ali-Osman F, Mangram A, Majercik S, White TW, et al. A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures. J Trauma Acute Care Surg. 2018;84(1):1–10. https://doi.org/10.1097/TA.0000000000001729Supports earlier surgery if rib fixation is going to be undertaken, with best outcomes in the first 24 hours.CrossRefPubMed

48.

Mowery NT, Gunter OL, Collier BR, Diaz JJ Jr, Haut E, Hildreth A, et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011;70(2):510–8. https://doi.org/10.1097/TA.0b013e31820b5c31.CrossRefPubMed

49.

Moore FO, Goslar PW, Coimbra R, Velmahos G, Brown CV, Coopwood TB Jr, et al. Blunt traumatic occult pneumothorax: is observation safe?--results of a prospective, AAST multicenter study. J Trauma. 2011;70(5):1019–23; discussion 23-5. https://doi.org/10.1097/TA.0b013e318213f727.CrossRefPubMed

50.

Staub LJ, Biscaro RRM, Kaszubowski E, Maurici R. Chest ultrasonography for the emergency diagnosis of traumatic pneumothorax and haemothorax: a systematic review and meta-analysis. Injury. 2018;49(3):457–66. https://doi.org/10.1016/j.injury.2018.01.033.CrossRefPubMed

51.

Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008;64(1):111–4. https://doi.org/10.1097/01.ta.0000239241.59283.03.CrossRefPubMed

52.

Inaba K, Ives C, McClure K, Branco BC, Eckstein M, Shatz D, et al. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012;147(9):813–8. https://doi.org/10.1001/archsurg.2012.751.CrossRefPubMed

53.

Inaba K, Karamanos E, Skiada D, Grabo D, Hammer P, Martin M, et al. Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers. J Trauma Acute Care Surg. 2015;79(6):1044–8. https://doi.org/10.1097/TA.0000000000000849.CrossRefPubMed

54.

American College of S, Committee on T. Advanced trauma life support : student course manual. Chicago, IL: American College of Surgeons; 2018.

55.

de Lesquen H, Avaro JP, Gust L, Ford RM, Beranger F, Natale C, et al. Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries). Interact Cardiovasc Thorac Surg. 2015;20(3):399–408. https://doi.org/10.1093/icvts/ivu397.CrossRefPubMed

56.

•• Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019;23(1):98. https://doi.org/10.1186/s13054-019-2347-3Excellent comprehensive review of the current understanding of managing bleeding and coagulopathy of trauma.CrossRefPubMedPubMedCentral

57.

Fox N, Schwartz D, Salazar JH, Haut ER, Dahm P, Black JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Nurs. 2015;22(2):99–110. https://doi.org/10.1097/JTN.0000000000000118.CrossRefPubMed

58.

Scalea TM, Feliciano DV, DuBose JJ, Ottochian M, O'Connor JV, Morrison JJ. Blunt thoracic aortic injury: endovascular repair is now the standard. J Am Coll Surg. 2019;228(4):605–10. https://doi.org/10.1016/j.jamcollsurg.2018.12.022.CrossRefPubMed

59.

Hanschen M, Kanz KG, Kirchhoff C, Khalil PN, Wierer M, van Griensven M, et al. Blunt cardiac injury in the severely injured - a retrospective multicentre study. PLoS One. 2015;10(7):e0131362. https://doi.org/10.1371/journal.pone.0131362.CrossRefPubMedPubMedCentral

60.

Nagy KK, Krosner SM, Roberts RR, Joseph KT, Smith RF, Barrett J. Determining which patients require evaluation for blunt cardiac injury following blunt chest trauma. World J Surg. 2001;25(1):108–11. https://doi.org/10.1007/s002680020372.CrossRefPubMed

61.

• Joseph B, Jokar TO, Khalil M, Haider AA, Kulvatunyou N, Zangbar B, et al. Identifying the broken heart: predictors of mortality and morbidity in suspected blunt cardiac injury. Am J Surg. 2016;211(6):982–8. https://doi.org/10.1016/j.amjsurg.2015.10.027Excellent summary of the risk factors for poor outcome in blunt cardiac injury.CrossRefPubMed

Title: Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries
Authors: Michelle Kim
James E. Moore
Publication date: 01-03-2020
Publisher: Springer US
Keywords: Thoracic Trauma
Pneumothorax
Pneumothorax
Pneumothorax
Rib Fracture
Hemothorax
Thoracic Trauma
Published in: Current Anesthesiology Reports / Issue 1/2020
Electronic ISSN: 2167-6275
DOI: https://doi.org/10.1007/s40140-020-00374-w

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries

Abstract

Purpose of Review

Recent Findings

Summary

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

Please log in to get access to this content

Other articles of this Issue 1/2020

Cardiopulmonary Exercise Testing for Preoperative Evaluation: What Does the Future Hold?

Role of Point-of-Care Ultrasound in the Early Stages of Trauma Care

Improving Surgical Outcomes and Patient Health: Perioperative Smoking Cessation Interventions

Preoperative Airway Evaluation

Enhanced Recovery After Surgery

Preoperative Assessment for Inpatients