Advertisement

Tracheostomy in trauma patients with rib fractures

  • Alexander FokinEmail author
  • Joanna Wycech
  • Kyle Chin Shue
  • Ryan Stalder
  • Jose Lozada
  • Ivan Puente
Original Article

Abstract

Purpose

Patients with rib fractures (RF) may require prolonged mechanical ventilation and tracheostomy. Indications for tracheostomy in trauma patients with RF remain debatable. The goal was to delineate characteristics of patients who underwent tracheostomy due to thoracic versus extra-thoracic causes, such as maxillofacial–mandibular injury (MFM), traumatic brain injury (TBI), and cervical vertebrae trauma (CVT), and to analyze clinical outcomes. The predictive values of chest trauma scoring systems for tracheostomy were also evaluated. We hypothesized that tracheostomized patients were more severely injured with more ribs fractured and had more pulmonary co-injuries.

Methods

Retrospective review included 471 patients with RF admitted to two Level 1 trauma centers. Patients with tracheostomy (n = 124, 26.3%) were compared to patients with endotracheal intubation (n = 347, 73.7%). Analyzed variables included age, gender, injury severity score (ISS), Glasgow Coma Scale, number of ribs fractured, total fractures of ribs, prevalence of bilateral rib fractures, flail chest, clavicle fractures, MFM, TBI, CVT, co-injuries, comorbidities, RF treatment options, hospital length of stay (HLOS), intensive care unit LOS (ICULOS), duration of mechanical ventilation (DMV).

Results

Tracheostomized compared to intubated patients had statistically higher ISS, more ribs fractured, total fractures of the ribs, bilateral and clavicle fractures, MFM, spine, chest, and orthopedic co-injuries and longer HLOS, ICULOS and DMV. Tracheostomy for thoracic reasons was performed in 64 patients (51.6%) and for extra-thoracic reasons in 60 patients (48.4%). Mean tracheostomy timing was 9.9 days and was significantly shorter in the extra-thoracic compared to the thoracic group (8.0 versus 11.6 days, p < 0.001). All chest trauma scoring system values were significantly higher in tracheostomized patients. Predictive values of scoring systems for tracheostomy increased in patients with thoracic trauma only.

Conclusions

A quarter of mechanically ventilated patients with RF required tracheostomy. Tracheostomized compared to intubated patients were more severely injured with more ribs fractured and were intubated longer. An increased amount of RF was associated with an increase in tracheostomies, especially for thoracic reasons.

Keywords

Tracheostomy Rib fractures Chest trauma Rib fracture scoring systems 

Notes

Compliance with ethical standards

Conflict of interest

Author Alexander Fokin, Author Joanna Wycech, Author Kyle Chin Shue, Author Ryan Stalder, Author Jose Lozada, and Author Ivan Puente declare that they have no conflict of interest.

Ethical statement

This manuscript has not been published previously or submitted elsewhere for publication and will not be sent to another journal until a decision is made concerning publication by the European Journal of Trauma and Emergency Surgery.

Ethical approval

This retrospective cohort study was approved by IRB. All procedures performed in the study involving human participants were in compliance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

The waiver of informed consent was granted by IRB.

References

  1. 1.
    Sirmali M, Turut H, Topcu S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003;24(1):133–8.CrossRefGoogle Scholar
  2. 2.
    Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37(6):975–9.CrossRefGoogle Scholar
  3. 3.
    Jones KM, Reed RL 2nd, Luchette FA. The ribs or not ribs: Which influences the mortality? Am J Surg. 2011;202:598–604.CrossRefGoogle Scholar
  4. 4.
    Flagel BT, Luchette FA, Reed RL, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138(4):717–23.CrossRefGoogle Scholar
  5. 5.
    Emond M, Sirois MJ, Guimont C, et al. Functional impact of a minor thoracic injury. Ann Surg. 2015;262(6):1115–22.CrossRefGoogle Scholar
  6. 6.
    Shulzhenko NO, Zens TJ, Beems MV, et al. Number of rib fractures thresholds independently predict worse outcomes in older patients with blunt trauma. Surgery. 2017;161(4):1083–9.CrossRefGoogle Scholar
  7. 7.
    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.CrossRefGoogle Scholar
  8. 8.
    Flores-Funes D, Lluna-Llorens AD, Jimenez-Ballester MA, et al. Is the number of rib fractures a risk factor for delayed complications? Eur J Trauma Emerg Surg. 2018.  https://doi.org/10.1007/s00068-018-1012-x.Google Scholar
  9. 9.
    Arabi Y, Haddad S, Shirawi N, Shimemeri AA. Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review. Crit Care. 2004;8(5):R347–52.CrossRefGoogle Scholar
  10. 10.
    Kane ED, Jeremitsky E, Bittner KR, Kartiko S, Doben AR. Surgical stabilization of rib fractures: a single institution experience. J Am Coll Surg. 2018;226(6):961–6.CrossRefGoogle Scholar
  11. 11.
    Dehghan N, Mah JM, Schemitsch EH, Nauth A, Vicente M, McKee MD. Operative stabilization of flail chest injuries reduces mortality to that of stable chest wall injuries. J Orthop Trauma. 2018;32(1):15–21.CrossRefGoogle Scholar
  12. 12.
    Easter A. Management of patients with multiple rib fractures. Am J Crit Care. 2001;10(5):320–7.Google Scholar
  13. 13.
    Pressley CM, Fry WR, Philp AS, Berry SD, Smith RS. Predicting outcome of patients with chest wall injury. Am J Surg. 2012;204(6):910–3.CrossRefGoogle Scholar
  14. 14.
    Chen J, Jeremitsky E, Philp F, Fry W, Smith RS. A chest trauma scoring system to predict outcomes. Surgery. 2014;156(4):988–94.CrossRefGoogle Scholar
  15. 15.
    Chapman BC, Herbert B, Rodil M, et al. RibScore: a novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy. J Trauma Acute Care Surg. 2016;80(1):95–101.CrossRefGoogle Scholar
  16. 16.
    Fokin AA, Wycech J, Crawford M, Puente I. Quantification of rib fractures by different scoring systems. J Surg Res. 2018;229(9):1–8.CrossRefGoogle Scholar
  17. 17.
    Miller C, Stolarski A, Ata A, et al. Impact of blunt pulmonary contusion in polytrauma patients with rib fractures. Am J Surg. 2019.  https://doi.org/10.1016/j.amjsurg.2019.01.027.Google Scholar
  18. 18.
    Quality of life after mechanized ventilation in the elderly study investigators. 2-month mortality and functional status of critically ill adult patients receiving prolonged mechanical ventilation. Chest. 2002;121(2):549–58.CrossRefGoogle Scholar
  19. 19.
    Beks RB, Peek J, de Jong MB, et al. Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis. Eur J Trauma Emerg Surg;. 2018.  https://doi.org/10.1007/s00068-018-1020-x.Google Scholar
  20. 20.
    Althausen PL, Shannon S, Watts C, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011;25(11):641–7.CrossRefGoogle Scholar
  21. 21.
    Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76(2):462–8.CrossRefGoogle Scholar
  22. 22.
    Pieracci FM, Majercik S, Ali-Osman F, et al. Consensus statement: surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury. 2017;8(2):307–21.CrossRefGoogle Scholar
  23. 23.
    Fokin AA, Wycech J, Weisz R, Puente I. Outcome analysis of surgical stabilization of rib fractures in trauma patients. J Orthop Trauma. 2019;33(1):3–8.Google Scholar
  24. 24.
    Stahl D, Ellington M, Brennan K, Brennan M. Association of ipsilateral rib fractures with displacement of midshaft clavicle fractures. J Orthop Trauma. 2017;31(4):225–8.CrossRefGoogle Scholar
  25. 25.
    Fokin A, Wycech J, Picard E, Weisz R, Puente I. Is first rib fracture a culprit or a sign of injury severity? It is both. J Orthop Trauma. 2018;32(8):391–6.CrossRefGoogle Scholar
  26. 26.
    Casamento A, Bailey M, Robbins R, et al. Patient characteristics, incidence, technique, outcomes and early prediction of tracheostomy in the state of Victoria, Australia. J Crit Care. 2018;44:278–84.CrossRefGoogle Scholar
  27. 27.
    Alsherbini K, Goyal N, Metter EJ, et al. Predictors for tracheostomy with external validation of the stroke-related early tracheostomy score (SETscore). Neurocrit Care. 2019;30(1):185–92.CrossRefGoogle Scholar
  28. 28.
    Kaji AH, Schringer D, Green S. Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies. Ann Emerg Med. 2014;64(3):292–8.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Alexander Fokin
    • 1
    Email author
  • Joanna Wycech
    • 1
    • 2
  • Kyle Chin Shue
    • 3
  • Ryan Stalder
    • 5
  • Jose Lozada
    • 2
  • Ivan Puente
    • 1
    • 2
    • 3
    • 4
  1. 1.Division of Trauma and Critical Care ServicesDelray Medical CenterDelray BeachUSA
  2. 2.Division of Trauma and Critical Care ServicesBroward Health Medical CenterFort LauderdaleUSA
  3. 3.Charles E. Schmidt College of Medicine, Department of SurgeryFlorida Atlantic UniversityBoca RatonUSA
  4. 4.Herbert Wertheim College of Medicine, Department of SurgeryFlorida International UniversityMiamiUSA
  5. 5.Wake Forest UniversityWinston-SalemUSA

Personalised recommendations