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Medical Management of Rib Fractures

  • Tashinga Musonza
  • S. Rob Todd
Chapter

Abstract

Rib fractures are reported in at least 10% of all trauma admissions. The associated morbidity and mortality worsen with advanced age and increasing number of rib fractures. In this population, the risk of nosocomial pneumonia has been documented to be as high as 29%. The utilization of clinical care pathways results in favorable outcomes. Despite this evidence, the medical management of rib fractures is yet to be truly standardized. At the core of recommended clinical care pathways is the identification of high-risk patients, appropriate patient disposition, multimodal pain control, aggressive pulmonary care, nutritional support, and early mobilization.

Keywords

Rib fractures Pain management for rib fractures Epidural Paravertebral Clinical care pathways for rib fracture Pneumonia 

References

  1. 1.
    Bergeron E, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478–85.CrossRefPubMedGoogle Scholar
  2. 2.
    Bulger EM, et al. Rib fractures in the elderly. J Trauma. 2000;48(6):1040–6. discussion 1046-7CrossRefPubMedGoogle Scholar
  3. 3.
    Todd SR, 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.CrossRefPubMedGoogle Scholar
  4. 4.
    Holcomb JB, et al. Morbidity from rib fractures increases after age 45. J Am Coll Surg. 2003;196(4):549–55.CrossRefPubMedGoogle Scholar
  5. 5.
    Sano A, Tashiro K, Fukuda T. Cough-induced rib fractures. Asian Cardiovasc Thorac Ann. 2015;23(8):958–60.CrossRefPubMedGoogle Scholar
  6. 6.
    Newgard CD, et al. Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a north American prospective cohort. Ann Emerg Med. 2010;55(3):235–246.e4.CrossRefPubMedGoogle Scholar
  7. 7.
    Teixeira PG, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma. 2007;63(6):1338–46. discussion 1346-7CrossRefPubMedGoogle Scholar
  8. 8.
    Pulley BR, et al. Utility of three-dimensional computed tomography for the surgical management of rib fractures. J Trauma Acute Care Surg. 2015;78(3):530–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Murphy CEt, et al. Rib fracture diagnosis in the Panscan era. Ann Emerg Med. 2017 Dec;70(6):904–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Ismailov RM, et al. Trauma associated with cardiac dysrhythmias: results from a large matched case-control study. J Trauma. 2007;62(5):1186–91.CrossRefPubMedGoogle Scholar
  11. 11.
    Al-Hassani A, et al. Rib fracture patterns predict thoracic chest wall and abdominal solid organ injury. Am Surg. 2010;76(8):888–91.PubMedGoogle Scholar
  12. 12.
    Ho SW, et al. Risk of pneumonia in patients with isolated minor rib fractures: a nationwide cohort study. BMJ Open. 2017;7(1):e013029.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Carver TW, et al. Vital capacity helps predict pulmonary complications after rib fractures. J Trauma Acute Care Surg. 2015;79(3):413–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Larsson L, Friedrich O. Critical illness myopathy (CIM) and ventilator-induced diaphragm muscle dysfunction (VIDD): acquired myopathies affecting contractile proteins. Compr Physiol. 2016;7(1):105–12.CrossRefPubMedGoogle Scholar
  15. 15.
    Mankowski RT, et al. Intraoperative hemidiaphragm electrical stimulation reduces oxidative stress and upregulates autophagy in surgery patients undergoing mechanical ventilation: exploratory study. J Transl Med. 2016;14(1):305.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Vassilakopoulos T, Petrof BJ. A stimulating approach to ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med. 2017;195(3):281–2.PubMedGoogle Scholar
  17. 17.
    Yang Y, et al. Endotoxemia accelerates diaphragm dysfunction in ventilated rabbits. J Surg Res. 2016;206(2):507–16.CrossRefPubMedGoogle Scholar
  18. 18.
    Zhu X, et al. The role of calpains in ventilator-induced diaphragm atrophy. Intensive Care Med Exp. 2017;5(1):14.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Hall JC, et al. Prevention of respiratory complications after abdominal surgery: a randomised clinical trial. BMJ. 1996;312(7024):148–52. discussion 152-3CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Wahba RW. Perioperative functional residual capacity. Can J Anaesth. 1991;38(3):384–400.CrossRefPubMedGoogle Scholar
  21. 21.
    Gage A, et al. The effect of epidural placement in patients after blunt thoracic trauma. J Trauma Acute Care Surg. 2014;76(1):39–45. discussion 45-6CrossRefPubMedGoogle Scholar
  22. 22.
    Girard TD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126–34.CrossRefPubMedGoogle Scholar
  23. 23.
    Jaber S, et al. Clinical review: ventilator-induced diaphragmatic dysfunction--human studies confirm animal model findings! Crit Care. 2011;15(2):206.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Petrof BJ, Jaber S, Matecki S. Ventilator-induced diaphragmatic dysfunction. Curr Opin Crit Care. 2010;16(1):19–25.CrossRefPubMedGoogle Scholar
  25. 25.
    Pinsky MR. Cardiovascular issues in respiratory care. Chest. 2005;128(5):592S–7S.CrossRefPubMedGoogle Scholar
  26. 26.
    Huang CC, et al. Prediction of fluid responsiveness in acute respiratory distress syndrome patients ventilated with low tidal volume and high positive end-expiratory pressure. Crit Care Med. 2008;36(10):2810–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Marik PE, et al. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37(9):2642–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Finfer S, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350(22):2247–56.CrossRefPubMedGoogle Scholar
  29. 29.
    Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma. 2003;54(3):615–25.CrossRefPubMedGoogle Scholar
  30. 30.
    Yang Y, et al. Use of ketorolac is associated with decreased pneumonia following rib fractures. Am J Surg. 2014;207(4):566–72.CrossRefPubMedGoogle Scholar
  31. 31.
    Ho KY, Gan TJ, Habib AS. Gabapentin and postoperative pain--a systematic review of randomized controlled trials. Pain. 2006;126(1–3):91–101.CrossRefPubMedGoogle Scholar
  32. 32.
    Mathiesen O, Moiniche S, Dahl JB. Gabapentin and postoperative pain: a qualitative and quantitative systematic review, with focus on procedure. BMC Anesthesiol. 2007;7:6.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Wang L, et al. Ketamine added to morphine or hydromorphone patient-controlled analgesia for acute postoperative pain in adults: a systematic review and meta-analysis of randomized trials. Can J Anaesth. 2016;63(3):311–25.CrossRefPubMedGoogle Scholar
  34. 34.
    Weibel S, et al. Efficacy and safety of intravenous lidocaine for postoperative analgesia and recovery after surgery: a systematic review with trial sequential analysis. Br J Anaesth. 2016;116(6):770–83.CrossRefPubMedGoogle Scholar
  35. 35.
    Mohta M, et al. 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.CrossRefPubMedGoogle Scholar
  36. 36.
    Bulger EM, et al. Epidural analgesia improves outcome after multiple rib fractures. Surgery. 2004;136(2):426–30.CrossRefPubMedGoogle Scholar
  37. 37.
    Shapiro BS, et al. Comparative analysis of the paravertebral analgesic pump catheter with the epidural catheter in elderly trauma patients with multiple rib fractures. Am Surg. 2017;83(4):399–402.PubMedGoogle Scholar
  38. 38.
    Dennis M, et al. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet. 2009;373(9679):1958–65.CrossRefPubMedGoogle Scholar
  39. 39.
    Lilly CM, et al. Thrombosis prophylaxis and mortality risk among critically ill adults. Chest. 2014;146(1):51–7.CrossRefPubMedGoogle Scholar
  40. 40.
    Alberda C, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009;35(10):1728–37.CrossRefPubMedGoogle Scholar
  41. 41.
    Artinian V, Krayem H, DiGiovine B. Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients. Chest. 2006;129(4):960–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Taylor SJ, et al. A randomised controlled feasibility and proof-of-concept trial in delayed gastric emptying when metoclopramide fails: we should revisit nasointestinal feeding versus dual prokinetic treatment: achieving goal nutrition in critical illness and delayed gastric emptying: trial of nasointestinal feeding versus nasogastric feeding plus prokinetics. Clin Nutr ESPEN. 2016;14:1–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Taylor SJ, Manara AR, Brown J. Treating delayed gastric emptying in critical illness: metoclopramide, erythromycin, and bedside (cortrak) nasointestinal tube placement. JPEN J Parenter Enteral Nutr. 2010;34(3):289–94.CrossRefPubMedGoogle Scholar
  44. 44.
    Montejo JC, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med. 2010;36(8):1386–93.CrossRefPubMedGoogle Scholar
  45. 45.
    Casaer MP, Van den Berghe G. Nutrition in the acute phase of critical illness. N Engl J Med. 2014;370(13):1227–36.CrossRefPubMedGoogle Scholar
  46. 46.
    McClave SA, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med. 2005;33(2):324–30.CrossRefPubMedGoogle Scholar
  47. 47.
    SA MC. Guidelines for the provision and assessment of nutrition support therapy in the adult Criticall ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (a.S.P.E.N). JPEN J Parenter Enteral Nutr. 2009;33(3):277–316.CrossRefGoogle Scholar
  48. 48.
    Sirmali M, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003;24(1):133–8.CrossRefPubMedGoogle Scholar
  49. 49.
    Allen GS, Cox CS Jr. Pulmonary contusion in children: diagnosis and management. South Med J. 1998;91(12):1099–106.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Michael E. DeBakey Department of SurgeryBaylor College of MedicineHoustonUSA

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