Top

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Published in:

Open Access 01-12-2015 | Review

Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery

Authors: Annalise Unsworth, Kate Curtis, Stephen Edward Asha

Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Issue 1/2015

Abstract

Blunt chest trauma is associated with a high risk of morbidity and mortality. Complications in blunt chest trauma develop secondary to rib fractures as a consequence of pain and inadequate ventilation. This literature review aimed to examine clinical interventions in rib fractures and their impact on patient and hospital outcomes. A systematic search strategy, using a structured clinical question and defined search terms, was performed in MEDLINE, EMBASE, CINAHL and the Cochrane Library. The search was limited to studies of adult humans from 1990-March 2014 and yielded 977 articles, which were screened against inclusion/exclusion criteria. A hand search was then performed of the articles that met the eligibility criteria, 40 articles were included in this review. Each article was assessed using a quantitative critiquing guideline. From these articles, interventions were categorised into four main groups: analgesia, surgical fixation, clinical protocols and other interventions. Surgical fixation was effective in patients with flail chest at improving patient outcomes. Epidural analgesia, compared to both patient controlled analgesia and intravenous narcotics in patients with three or more rib fractures improved both hospital and patient outcomes, including pain relief and pulmonary function. Clinical pathways improve outcomes in patients ≥ 65 with rib fractures. The majority of reviewed papers recommended a multi-disciplinary approach including allied health (chest physiotherapy and nutritionist input), nursing, medical (analgesic review) and surgical intervention (stabilisation of flail chest). However there was a paucity of evidence describing methods to implement and evaluate such multidisciplinary interventions. Isolated interventions can be effective in improving patient and health service outcomes for patients with blunt chest injuries, however the literature recommends implementing strategies such as clinical pathways to improve the care and outcomes of thesetre patients. The implementation of evidence-practice interventions in this area is scarce, and evaluation of interventions scarcer still.

Available only for authorised users

Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma-Injury Infec Crit Care. 2000;48(6):1040–6. discussion 1046–1047.CrossRef

Lee RB, Bass SM, Morris Jr JA, MacKenzie EJ. Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study. J Trauma-Injury Infect Crit Care. 1990;30(6):689–94.CrossRef

Yeh DD, Kutcher ME, Knudson MM, Tang JF. Epidural analgesia for blunt thoracic injury–which patients benefit most? Injury. 2012;43(10):1667–71.CrossRefPubMed

Wardhan R. Assessment and management of rib fracture pain in geriatric population: an ode to old age. Curr Opin Anaesthesiol. 2013;26(5):626–31.CrossRef

Easter A. Management of patients with multiple rib fractures. Am J Crit Care. 2001;10(5):320–7.PubMed

Barnea Y, Kashtan H, Skornick Y, Werbin N. Isolated rib fractures in elderly patients: mortality and morbidity. Can J Surg. 2002;45(1):43–6.PubMedCentralPubMed

Elmistekawy E, Hammad AA. Isolated rib fractures in geriatric patients. Annals of Thoracic Med. 2007;2(4):166–8.CrossRef

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.PubMed

Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331(24):1601–6.CrossRefPubMed

10.

Brathwaite C, Mure A, O’Malley K, Spence R, Ross S. Complications of anticoagulation for pulmonary embolism in low risk trauma patients. CHEST J. 1993;104(3):718–20.CrossRef

11.

Gage A, Rivara F, Wang J, Jurkovich GJ, Arbabi S. The effect of epidural placement in patients after blunt thoracic trauma. J Trauma Acute Care Surg. 2014;76(1):39–46.CrossRefPubMed

12.

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-Injury Infect Crit Care. 2009;66(4):1096–101.CrossRef

13.

Møiniche S, Kehlet H, Dahl JB. A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief: the role of timing of analgesia. Anesthesiology. 2002;96(3):725–41.CrossRefPubMed

14.

Sackett D, Richardson W, Rosenberg W, Haynes R. Evidence-based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone; 1997.

15.

Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546–53.CrossRefPubMed

16.

Karmakar MK, Ho AM-H. Acute pain management of patients with multiple fractured ribs. J Trauma-Injury, Infect Crit Care. 2003;54(3):615–25.CrossRef

17.

Balkan ME, Oktar GL, Kayi-Cangir A, Ergul EG. Emergency thoracotomy for blunt thoracic trauma. Annals Thoracic Cardiovasc Surg. 2002;8(2):78–82.

18.

Kalina M, Teeple E, Fulda G. Are there still selected applications for resuscitative thoracotomy in the emergency department after blunt trauma? Del Med J. 2009;81(5):195–8.PubMed

19.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9.CrossRefPubMed

20.

Polit-O’Hara D, Hungler BP. Essentials of nursing research: methods, appraisal, and utilization. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 1993.

21.

Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Current methods of the US preventive services task force: a review of the process. Am J Prev Med. 2001;20(3):21–35.CrossRefPubMed

22.

Doben AR, Eriksson EA, Denlinger CE, Leon SM, Couillard DJ, Fakhry SM, et al. Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care. 2014;29(1):139–43.CrossRefPubMed

23.

Borman JB, Aharonson-Daniel L, Savitsky B, Peleg K. Unilateral flail chest is seldom a lethal injury. Emerg Med J. 2006;23(12):903–5.CrossRefPubMedCentralPubMed

24.

Freedland M, Wilson RF, Bender JS, Levison MA. The management of flail chest injury: factors affecting outcome. J Trauma-Injury Infect Crit Care. 1990;30(12):1460–8.CrossRef

25.

Althausen PL, Shannon S, Watts C, Thomas K, Bain MA, Coll D, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011;25(11):641–7.CrossRefPubMed

26.

Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP. Outcome of operative chest wall stabilization in flail chest with or without pulmonary contusion. [German]. Unfallchirurg. 1996;99(6):425–34.PubMed

27.

Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg. 2006;72(4):307–9.PubMed

28.

Tanaka HYT, Yamaguti Y, Shimizu S, Goto H, Matsuda H, Shimazaki S. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52(4):727–32. discussion 732.CrossRefPubMed

29.

Granetzny A, El-Aal MA, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Eval Pulm Status Interact Cardiovas Thoracic Surg. 2005;4(6):583–7.CrossRef

30.

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.CrossRefPubMed

31.

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 - Injury Infect Crit Care. 2011;71(6):1548–52.CrossRef

32.

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-Injury, Infect Crit Care. 1991;31(4):443–51.CrossRef

33.

Asha SE, Curtis KA, Taylor C, Kwok A. Patient-controlled analgesia compared with interval analgesic dosing for reducing complications in blunt thoracic trauma: a retrospective cohort study. Emerg Med J. 2013;30(12):1024–8.CrossRefPubMed

34.

Karmakar MK, Critchley LA, Ho AM-H, Gin T, Lee TW, Yim AP. Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs. CHEST J. 2003;123(2):424–31.CrossRef

35.

Ingalls NK, Horton ZA, Bettendorf M, Frye I, Rodriguez C. Randomized, double-blind, placebo-controlled trial using lidocaine patch 5% in traumatic rib fractures. J Am Coll Surg. 2010;210(2):205–9.CrossRefPubMed

36.

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.CrossRefPubMedCentralPubMed

37.

Wisner DH. A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: effect of epidural analgesia. J Trauma-Injury Infect Crit Care. 1990;30(7):799–804. discussion 804–795.CrossRef

38.

Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery. 2004;136(2):426–30.CrossRefPubMed

39.

Wu CL, Jani ND, Perkins FM, Barquist E. Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash. J Trauma-Injury Infect Crit Care. 1999;47(3):564–7.CrossRef

40.

Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious complications related to regional anesthesia: results of a prospective survey in France. Anesthesiology. 1997;87(3):479–86.CrossRefPubMed

41.

Zink KA, Mayberry JC, Peck EG, Schreiber MA. Lidocaine patches reduce pain in trauma patients with rib fractures. Am Surg. 2011;77(4):438–42.PubMed

42.

Shukla AN, Ghaffar ZBA, Auang AC, Rajah U, Tan L. Continuous paravertebral block for pain relief in unilateral multiple rib fracture: a case series. Acute Pain. 2008;10(1):39–44.CrossRef

43.

Sesperez J, Wilson S, Jalaludin B, Seger M, Sugrue M. Trauma case management and clinical pathways: prospective evaluation of their effect on selected patient outcomes in five key trauma conditions. J Trauma-Injury Infect Crit Care. 2001;50(4):643–9.CrossRef

44.

Wilson S, Bin J, Sesperez J, Seger M, Sugrue M. Clinical pathways–can they be used in trauma care. An Anal Patient Inj. 2001;32(7):525–32.

45.

Menditto VG, Gabrielli B, Marcosignori M, Screpante F, Pupita G, Polonara S, et al. A management of blunt thoracic trauma in an emergency department observation unit: pre-post observational study. J Trauma Acute Care Surg. 2012;72(1):222–8.PubMed

46.

Sahr SM, Webb ML, Renner CH, Sokol RK, Swegle JR. Implementation of a rib fracture triage protocol in elderly trauma patients. J Trauma Nurs. 2013;20(4):172–5.CrossRefPubMed

47.

Todd SR, McNally MM, Holcomb JB, Kozar RA, Kao LS, Gonzalez EA, et al. A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. Am J Surg. 2006;192(6):806–11.CrossRefPubMed

48.

Adrales G, Huynh T, Broering B, Sing RF, Miles W, Thomason MH, et al. A thoracostomy tube guideline improves management efficiency in trauma patients. J Trauma-Inj Infect Crit Care. 2002;52(2):210–4. discussion 214–216.CrossRef

49.

Bolliger CT, Van Eeden SF. Treatment of multiple rib fractures. Randomized controlled trial comparing ventilatory with nonventilatory management Chest. 1990;97(4):943–8.

50.

Walz M, Mollenhoff G, Muhr G. CPAP-augmented spontaneous respiration in thoracic trauma. An alternative to intubation. Unfallchirurg. 1998;101(7):527–36.CrossRefPubMed

51.

Gunduz M, Unlugenc H, Ozalevli M, Inanoglu K, Akman H. A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest. Emerg Med J. 2005;22(5):325–9.CrossRefPubMedCentralPubMed

52.

Fabbrucci P, Nocentini L, Secci S, Manzoli D, Bruscino A, Fedi M, et al. Video-assisted thoracoscopy in the early diagnosis and management of post-traumatic pneumothorax and hemothorax. Surg Endosc. 2008;22(5):1227–31.CrossRefPubMed

53.

Smith JW, Franklin GA, Harbrecht BG, Richardson JD. Early VATS for blunt chest trauma: a management technique underutilized by acute care surgeons. J Trauma-Inj Infect Crit Care. 2011;71(1):102–5. discussion 105–107.CrossRef

54.

Quick G. A randomized clinical trial of rib belts for simple fractures. Am J Emerg Med. 1990;8(4):277–81.CrossRefPubMed

55.

Avery E, Benson D, Morch E. Critically crushed chests; a new method of treatment with continuous mechanical hyperventilation to produce alkalotic apnea and internal pneumatic stabilization. J Thorac Surg. 1956;32(3):291–311.PubMed

56.

Chiumello D, Coppola S, Froio S, Gregoretti C, Consonni D. Noninvasive ventilation in chest trauma: systematic review and meta-analysis. Intensive Care Med. 2013;39(7):1171–80.CrossRefPubMed

57.

Shackford SR, Smith DE, Zarins CK, Rice CL, Virgilio RW. The management of flail chest: a comparison of ventilatory and nonventilatory treatment. Am J Surg. 1976;132(6):759–62.CrossRefPubMed

58.

Trinkle JK, Richardson JD, Franz JL, Grover FL, Arom KV, Holmstrom FM. Management of flail chest without mechanical ventilation. Ann Thorac Surg. 1975;19(4):355–63.CrossRefPubMed

59.

Pettiford BL, Luketich JD, Landreneau RJ. The management of flail chest. Thorac Surg Clin. 2007;17(1):25–33.CrossRefPubMed

60.

De Moya M, Bramos T, Agarwal S, Fikry K, Janjua S, King DR, et al. Pain as an indication for rib fixation: a bi-institutional pilot study. J Trauma - Inj, Infect Crit Care. 2011;71(6):1750–4.CrossRef

61.

Schwed AC, Sonnad SS, Holena DN, Pascual JL, Reilly PM, Sims CA. Take a deep breath!: managing rib fractures in elderly trauma patients. J Surg Res. 2013;179:2.CrossRef

62.

Barrett-Connor E, Nielson CM, Orwoll E, Bauer DC, Cauley JA. Epidemiology of rib fractures in older men: osteoporotic fractures in men (MrOS) prospective cohort study. BMJ. 2010;00:00 2010:340.

63.

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 - Inj Infect Crit Care. 2003;54(3):478–85.CrossRef

64.

Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37(6):975–9.CrossRefPubMed

65.

Sharma OP, Oswanski MF, Jolly S, Lauer SK, Dressel R, Stombaugh HA. Perils of rib fractures. Am Surg. 2008;74(4):310–4.PubMed

66.

Winters BA. older adults with traumatic rib fractures: an evidence based approach to their care. Int J Trauma Nurs. 2009;16(2):93–7.

67.

Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma-Inj Infect Crit Care. 2002;52(6):1141–6.CrossRef

68.

Hunter B, Segrott J. Re-mapping client journeys and professional identities: a review of the literature on clinical pathways. Int J Nurs Stud. 2008;45(4):608–25.CrossRefPubMed

69.

Rotter T, Kugler J, Koch R, Gothe H, Twork S, van Oostrum JM, et al. A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes. BMC Health Serv Res. 2008;8(1):265.CrossRefPubMedCentralPubMed

70.

Vanhaecht K, Panella M, Van Zelm R, Sermeus W. An overview on the history and concept of care pathways as complex interventions. Intl J Care Pathw. 2010;14(3):117–23.CrossRef

71.

Goldberger JJ, Buxton AE. Personalized medicine vs guideline-based medicine. Jama. 2013;309(24):2559–60.CrossRefPubMed

72.

Bansidhar BJ, Lagares-Garcia JA, Miller S. Clinical rib fractures: are follow-up chest X-rays a waste of resources? Am Surg. 2002;68(5):449–53.PubMed

73.

Campbell H, Hotchkiss R, Bradshaw N, Porteous M. Integrated care pathways. BMJ: British Med J. 1998;316(7125):133.CrossRef

74.

Curtis K, Zou Y, Morris R, Black D. Trauma case management: improving patient outcomes. Injury. 2006;37(7):626–32.CrossRefPubMed

75.

Dutton RP, Cooper C, Jones A, Leone S, Kramer ME, Scalea TM. Daily multidisciplinary rounds shorten length of stay for trauma patients. J Trauma-Inj Infect Crit Care. 2003;55(5):913–9.CrossRef

76.

Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31(5):243–8.PubMed

77.

Huber S, Biberthaler P, Delhey P, Trentzsch H, Winter H, van Griensven M, et al. Predictors of poor outcomes after significant chest trauma in multiply injured patients: a retrospective analysis from the German Trauma Registry (Trauma Register DGU®). Scand J Trauma Resusc Emerg Med. 2014;22(1):52–2.CrossRefPubMed

78.

Geiger EV, Lustenberger T, Wutzler S, Lefering R, Lehnert M, Walcher F, et al. Predictors of pulmonary failure following severe trauma: a trauma registry-based analysis. Scand J Trauma Resusc Emerg Med. 2013;21(1):34.CrossRefPubMedCentralPubMed

79.

Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144(8):596–608.CrossRefPubMed

80.

Cohn MDLH, Rosborough RND, Fernandez MPAJ. Reducing costs and length of stay and improving efficiency and quality of care in cardiac surgery. Ann Thorac Surg. 1997;64(6):S58–60.CrossRefPubMed

81.

Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg. 2003;23(3):374–8.CrossRefPubMed

82.

Clini E, Ambrosino N. Early physiotherapy in the respiratory intensive care unit. Respir Med. 2005;99(9):1096–104.CrossRefPubMed

83.

Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg. 1995;110(6):1676–80.CrossRefPubMed

84.

Hakim SM, Latif FS, Anis SG. Comparison between lumbar and thoracic epidural morphine for severe isolated blunt chest wall trauma: a randomized open-label trial. J Anesth. 2012;26(6):836–44.CrossRefPubMed

85.

Topcu I, Ekici Z, Sakarya M. [Comparison of clinical effectiveness of thoracic epidural and intravenous patient-controlled analgesia for the treatment of rib fractures pain in intensive care unit]. Ulusal Travma ve Acil Cerrahi Dergisi = Turkish J Trauma & Emerg Surg: TJTES. 2007;13(3):205–10.

86.

Kieninger AN, Bair HA, Bendick PJ, Howells GA. Epidural versus intravenous pain control in elderly patients with rib fractures. Am J Surg. 2005;189(3):327–30.CrossRefPubMed

87.

Pierre EJ, Martin P, Frohock J, Varon AJ, Barquist E. Lumbar epidural morphine versus. Patient-controlled analgesia morphine in patients with multiple rib fractures. Anesthesiology. 2005;103(A289):A289.

88.

Lohr KN. Rating the strength of scientific evidence: relevance for quality improvement programs. Int J Qual Health Care. 2004;16(1):9–18.CrossRefPubMed

Title: Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery
Authors: Annalise Unsworth
Kate Curtis
Stephen Edward Asha
Publication date: 01-12-2015
Publisher: BioMed Central
Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine / Issue 1/2015
Electronic ISSN: 1757-7241
DOI: https://doi.org/10.1186/s13049-015-0091-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 1/2015

A mobile minimally invasive interventional shelter: a new answer to on-spot emergency treatment of large arterial injuries?

Cranioplasty complications and risk factors associated with bone flap resorption

The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study

Emergency surgery in the elderly: the balance between function, frailty, fatality and futility

Physicians using ultrasound in Danish emergency departments are mostly summoned specialists

Exposure and posttraumatic stress symptoms among first responders working in proximity to the terror sites in Norway on July 22, 2011 – a cross-sectional study