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5/7/2018
1
Chest Wall Trauma
Jonathan Messing
MSN, ACNP‐BC, CCRN, TCRN
Disclosures
• None
Objectives
• Describe chest wall trauma and concomitant injuries
• Compare and Contrast Standards of Care with Novel Pharmacologic Therapies
• Identify Indications, Advantages, and Disadvantages of Surgical Fixation of Fractured Ribs
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What is the chest wall?
• Ribs
• Clavicles
• Sternum
• Scapula
• Form & Function
Epidemiology
Blunt Penetrating
Energy
Rib Fractures
BlastBlast
ShearShear
CompressionCompression
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Lethal Injuries
AirwayAirway
O2/VentO2/Vent
HemorrhageHemorrhageCardiac FailureCardiac Failure
Cardiac TamponadeCardiac
Tamponade
Protecting Important Structures
• Heart
• Aorta and its branches
• Pulmonary Artery
• Vena Cava
• Lungs
• Trachea
• Bronchi
• Esophagus
• Diaphragm
Concomitant Injuries
• Simple pneumothorax
• Tension Pneumothorax
• Blunt cardiac injury
• Pulmonary contusion
• Aortic transection
• Tracheobronchial injury
• Livers Laceration
• Kidney Laceration
• Hemothorax
• Open pneumothorax
• Traumatic Chylothorax
• Cardiac Tamponade
• Cardiac laceration
• Ruptured diaphragm
• Splenic Laceration
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Pulmonary Contusions
• Why alarming?
• What’s the duration?
Case I – EMS call in
• 37 F
• Motorcycle crash
• Decreased breath sounds on right
• Right knee deformity
Where to start?
• Stick to the basics
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Primary Survey
• A – Speaking, in cervical collar
• B – Right sided crepitus, chest wall instability
• C – palpable left radial pulse, HR 90, SBP 110, sat 96% on 2L, no gross hemorrhage
• D – GCS 15, PERRL, MAE
• E – Road rash
Secondary Survey
• Head
• Neck
• Chest
• Abdomen/Pelvis
• Extremities
Imaging
Carr JJ, Reed JC, Choplin RH, et al. Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients. Radiology 1992; 183(1): 193‐9.
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Imaging
Flail chest
• What is it?
What is concerning here?
• How can a rib fracture kill you?
Bergeron E, Lavoie A, Clas D, et al. Elderly trauma patients with rib fractures are at a greater risk of death and pneumonia. J Trauma 2003; 54(3): 479‐85.
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Fractures and the Elderly
Bulger EM, ArenesonMA, Mock CN, et al. Rib fractures in the elderly. J Trauma 2000; 48(6): 1040‐7.
What about slightly younger?
Holcomb JB, McMullin NR, Kozar RA, et al. Morbidity from rib fractures increases after age 45. J Am Coll Surg2003; 196(4): 549‐555.
Why does this matter?
Jones KM, Reed RL, Luchette FA. Ribs or not the ribs: which influences mortality? Am J Surg 2011; 202(5): 598‐604.
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Treatment
MedicalMedical
SurgicalSurgical
NursingNursing
RecoveryRecovery
Placement
• Laws of The House of God
V. Placement comes first
‐ Samuel Shem
Brasel KJ, Moore EE, Albrecht RA, et al. Western Trauma Association critical decisions in trauma: management of rib fractures. J Trauma Acute Care Surg 2016; 82(1): 200‐3.
Medical Management
Pain ControlPain ControlMVMV
FluidsFluids
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Pain in trauma
TransductionTransduction TransmissionTransmission PerceptionPerception ModulationModulation
Oyler DR, Parli SE, Bernard AC, et al. Nonopioidmanagement of acute pain associated with trauma: focus on pharmacologic options. J Trauma Acute Care Surg 2015; 79(3): 475‐83.
Failure to treat
• Exaggerated Stress Response
• Chronic pain syndrome
• PTSD
Fabricant L, Ham B, Mullins R, et al. Prolonged pain and disability are common after rib fractures. Am J Surg 2013; 205: 511‐6.
Where to start
• Depends on the patient
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Pain• Opioids
– Morphine
– Hydromorphone
– Hydrocodone
– Fentanyl
• Route– IV, PO, etc.
– PCA• With/without basal
• AACA
• Non‐opioids– Regional blocks
– Ketamine
– Acetaminophen
– NSAIDs, COX‐2 inhibitors
– Gabapentin
– Alpha‐2 agonists
– Muscle relaxants
– Transdermal Lidocaine
– Non‐pharmacologic
– Antidepressants
Non‐opioids
Acetaminophen
Advantages
Disadvantages
Non‐opioids: NSAIDS
Non‐selective COX Inhibitors
Advantages
Disadvantages
COX‐2 Inhibitors
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Opioids
Advantages
• Rapid
• Effective
• Numerous routes
• Inexpensive
Limitations
• Respiratory
• CNS
• GI
• Heme
• Derm
• GU
Opioids
OpioidsOpioids
MorphineMorphine
HydromorphoneHydromorphone
FentanylFentanyl
Personally Controlled Analgesia
PCA
• Saves time
• Empowers patients
• Provides data
AACA
• Improves pain control
• Saves time
• Prevents higher doses
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Ketamine
Category?
• General anesthetic
Mechanism? Pd? Pk?
• NMDA receptor antagonist
• Onset: 30 seconds when IV
• Duration: 5‐10 mins IV
• Metabolized Hepatically
Ketamine
Adverse Reactions?
• Emergence Reaction
Contraindications?
• Schizophrenia
• Age < 3 months
• Elevated ICP?
• Cardiac Ischemia
• PTSD?
Laskowski K, Stirling A, McKay WP, et al. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anesth 2011; 58: 911‐23.
Patanwala AE, Martin JR, Erstad BL. Ketamine for analgosedation in the intensive care unit: a systematic review. J Intens Care Med 2015.
Other options
• Transdermal Lidocaine
• Lidocaine Infusions
• Skeletal Muscle Relaxants
• TENS
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Regional blocks
KaramakarMK, Ho A. Acute pain management of patients with multiple rib fractures. J Trauma 2003; 54(3): 615‐25.
Thoracic Epidural Anesthesia
Pros
• Ease of placement
• Effective
• Can include personally controlled component
Cons
• Hemodynamics
• Coagulopathy limitations
• Sympathectomy
• Mobility impairment
Paravertebral Nerve Blockade
• What are they?
• Advantages?
• Complications?
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Intercostal Nerve Blocks
• Single injection vscontinuous
• Can be tedious
• Not limited by anticoagulation
Truitt MS, Murry J, Amos J, et al. Continuous intercostal nerve blockade for rib fractures: ready for primetime? J Trauma 2011; 71(6): 1548‐52.
Pre PostSMI 0.4L 1.3L
Interpleural
‐ Blocks multiple dermatomes
‐ Can be lost via chest tubes
Non‐pharmacologic
• Heat
• Ice
• Reiki Therapy
• Physical and Occupational Therapy
• Repositioning
• Distraction
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Nursing ImplicationsNursing
Implications
Incentive SpirometryIncentive Spirometry
Out of bedOut of bed
PT/OTPT/OT
Chest PTChest PT
TheravestTheravest
TCDBTCDB
Back to our patient…
• Right ribs 3‐12 fractured
• Flail chest
• Pneumothorax
Case I ‐Management
• Paravertebrals
• fPCA
• Acetaminophen
• Celecoxib
• Ketamine
• And…
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Failure of medical management
Scoring systems
Pressley CM, Fry WR, Philp AS, et al. Predicting outcome of patients with chest wall injury. Am J Surg 2012; 204(6): 910‐3.
7 points or more = 14.3% Mortality (p = 0.0018)
Chest Trauma Scoring System
Chen J, Jeremitsky E, Philp F, et al. A chest trauma scoring system to predict outcomes. Surgery 2014; 156(4): 988‐93.
Greater than 4 points:Mortality 9%PNA 10.1%
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RibScore
6 or more rib fx 1 pointBilateral rib fx 1 pointFlail chest 1 point3 or more bicortical fx 1 point1st rib fx 1 point1 or more fx in each of 3 anatomic areas 1 point
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.
Predicting failure
• IS
• Deep breathing
• Coughing
• Speaking
• Mobility
Rib fractures in the eldery
Self reportSelf report
ObserveObserve
Other reportsOther reports
Trial Medications
Trial Medications
IS or VCIS or VC
Winters BA. Older Adults with traumatic rib fractures: an evidence based approach to their care. J Trauma Nurs 2009; 16(2): 93‐7.
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Surgical Fixation
• Why?
• Benefits
Indications
Sarani B, Schulte L, Diaz J. Pitfalls associated with open reduction and internal fixation of fractured ribs. Int J Care Injured 2015; 46: 2335‐40.
Contraindications
Pulmonary Contusions?Pulmonary Contusions?
Severe Injuries?Severe Injuries?
Instability?Instability?
Acute Resp. Failure?
Acute Resp. Failure?
Infection?Infection?
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What do we know so far?
• Review of studies for rib plating
Slobogean 2013
Slobogean GP, MacPherson CA, Sun T, et al. Surgical fixation vs nonoperativemanagement of flail chest: a meta‐analysis. J Am Coll Surg 2013; 216(2): 302‐11.
Pieracci 2016
Pieracci FM, Lin Y, Rodil M, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg 2016; 80(2): 187‐94.
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Lengths of stay
Kocher GJ, Sharafi S, Azenha LF, et al. Chest wall stabilization in ventilator‐dependent traumatic flail chest patients: who benefits. European Journal of Cardiothoracic Surgery2016.Majercik S, Wilson E, Gardner S, et al. In‐hospital outcomes and costs of surgical stabilization versus nonoperative management of severe rib fractures. J Trauma Acute Care Surg 2014; 79(4): 533‐9.
Reduced infection
Majercik S, Vijayakumar S, Olsen G, et al. Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema. Am J Surg 2015; 210(6): 1112‐7.
Plating the elderly
Fitzgerald MT, Ashley DW, Abukhdeir H, et al: Rib fracture fixation in the 65 years and older population: a paradigm shift in management strategy at a level I trauma center. J Trauma Acute Care Surg 2017; 82(3): 524‐7.
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EAST PMG
Kasotakis G, Hasenboehler EA, Streib EW, 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 2016; ePub ahead of print.
To PlateTo PlateNot to PlateNot to Plate
OR
So who should we plate?
• Non‐TBI patients with flail chest that can be plated early
Case I ‐ Rib Plating
• Hospital Day 2
• Ribs 5‐9 plated through an 8 cm transverse thoracic incision
• Procedure time 1 hour 45 minutes
• Extubated same day
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Case I ‐ Post‐op Imaging
Post‐op care
• Chest tube?
• Pain control!
• Ambulation
Case II
• 71M Ped Struck
• Polytrauma
• Ketamine infusion
• AACA hydromorphone
• Gabapentin
• Transdermal lidoderm
• Lidocaine infusion
• Paravertebral blockade
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Case II
0200 Seizure Activity
0200 Seizure Activity
Head CT: NormalHead CT: Normal
??
Local Anesthetic Systemic Toxicity
Prodromal Symptoms
Seizures
LOC
Agitation
CNSCNS HR changes
Ectopy
ST segment changes
Hypo/Hypertension
CVCV
Dickerson DM, Apfelbaum JF. Local anesthetic systemic toxicity. AesthetSurg J 2014; 34(7): 1111‐9.
El‐Boghdadly K, Chin KJ. Local anesthestic systemic toxicity: continuing professional development. Can J Anaesth 2016; 63(3): 330‐49.
Local Anesthetic Systemic Toxicity
El‐Boghdadly K, Chin KJ. Local anesthestic systemic toxicity: continuing professional development. Can J Anaesth 2016; 63(3): 330‐49.
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LAST Treatment
AirwayAirway • ACLS
SeizuresSeizures • Benzos
LipidsLipids • 20% Emulsion
Dickerson DM, Apfelbaum JF. Local anesthetic systemic toxicity. AesthetSurg J 2014; 34(7): 1111‐9.
El‐Boghdadly K, Chin KJ. Local anesthestic systemic toxicity: continuing professional development. Can J Anaesth 2016; 63(3): 330‐49.
Case III
• 85 yo female presents after choking on food
• CPR with ROSC and normal MS
• Extubated
• Injuries: flail sternum, bilateral rib fractures of 2‐8
Rib plating after CPR
McKay DR, Fawzy HF, McKay KM, et al. Are chest compressions safe for the patient reconstructed with sternal plates? Evaluating the safety of cardiopulmonary resuscitation using a human cadaveric model. J Cardiothoracic Surg 2010; 18.
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Case IV – Bicyclist Struck
Chest wall failure
Post ORIF
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Take home messages
• Value the clinical exam
• Optimize medical management
• Provide multimodal pain therapy + regional blocks
• We need more data needed on SSRF, but early results promising
• Remember limitations of local anesthetics
ReferencesBergeron E, Lavoie A, Clas D, et al. Elderly trauma patients with rib fractures are at a greater risk of death and pneumonia. J Trauma 2003; 54(3): 479‐85.
Brasel KJ, Moore EE, Albrecht RA, et al. Western Trauma Association critical decisions in trauma: management of rib fractures. J Trauma Acute Care Surg2016; 82(1): 200‐3.
Brown SD, Walters MR. Patients with rib fractures: use of incentive spirometry to guide care. J Trauma Nurs 2012; 19(2): 92‐3.
Bulger EM, Areneson MA, Mock CN, et al. Rib fractures in the elderly. J Trauma 2000; 48(6): 1040‐7.
Carr JJ, Reed JC, Choplin RH, et al. Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients. Radiology 1992; 183(1): 193‐9.
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.
Chen J, Jeremitsky E, Philp F, et al. A chest trauma scoring system to predict outcomes. Surgery 2014; 156(4): 988‐93.
Choi JJ, Lin E, Gadsden J. Regional anesthesia for trauma outside the operating theatre. Curr Opin Anaesthesiol 2013; 26(4): 495‐500.
Cooney MF, Czarnecki M, Dunwoody C, et al: American society for pain management nursing position statement with clinical practice guidelines: authorized agent controlled analgesia. Pain Manag Nurs 2013; 14(3): 176‐81.
Dickerson DM, Apfelbaum JF. Local anesthetic systemic toxicity. Aesthet Surg J 2014; 34(7): 1111‐9.
El‐Boghdadly K, Chin KJ. Local anesthestic systemic toxicity: continuing professional development. Can J Anaesth 2016; 63(3): 330‐49.
Fabricant L, Ham B, Mullins R, et al. Prolonged pain and disability are common after rib fractures. Am J Surg 2013; 205: 511‐6.
Fitzgerald MT, Ashley DW, Abukhdeir H, et al: Rib fracture fixation in the 65 years and older population: a paradigm shift in management strategy at a level I trauma center. J Trauma Acute Care Surg 2017; 82(3): 524‐7.
References
Galvagno SM, Smith CE, Varon AJ, 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.
Ho AM, Karmakar MK, Critchley LA. Acute pain management of patients with multiple rib fractures: a focus on regional techniques. Curr Opin Crit Care 2011; 17: 323‐7.
Holcomb JB, McMullin NR, Kozar RA, et al. Morbidity from rib fractures increases after age 45. J Am Coll Surg 2003; 196(4): 549‐555.
Jones KM, Reed RL, Luchette FA. Ribs or not the ribs: which influences mortality? Am J Surg 2011; 202(5): 598‐604.
Karamakar MK, Ho A. Acute pain management of patients with multiple rib fractures. J Trauma 2003; 54(3): 615‐25.
Kasotakis G, Hasenboehler EA, Streib EW, 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 2016; ePub ahead of print.
Katzung BG. Basic and clinical pharmacology. 10th ed. McGraw Hill 2007.
Khandar SJ, Johnson SB, Calhoon JH. Overview of thoracic trauma in the united states. Thorac Surg Clin 2007.
Kiraly L, Schreiber M. Management of the crushed chest. Crit Care Med 2010; 38(9): s469‐77.
Kocher GJ, Sharafi S, Azenha LF, et al. Chest wall stabilization in ventilator‐dependent traumatic flail chest patients: who benefits. European Journal of Cardiothoracic Surgery 2016.
Laskowski K, Stirling A, McKay WP, et al. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anesth 2011; 58: 911‐23.
Majercik S, Vijayakumar S, Olsen G, et al. Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema. Am J Surg2015; 210(6): 1112‐7.
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References
Majercik S, Wilson E, Gardner S, et al. In‐hospital outcomes and costs of surgical stabilization versus nonoperative management of severe rib fractures. J Trauma Acute Care Surg 2014; 79(4): 533‐9.
McKay DR, Fawzy HF, McKay KM, et al. Are chest compressions safe for the patient reconstructed with sternal plates? Evaluating the safety of cardiopulmonary resuscitation using a human cadaveric model. J Cardiothoracic Surg 2010; 18.
Messing JA, Gall V, Sarani B. Successful management of severe flail chest via early operative intervention. J Trauma Nurs 2014; 21(2): 83‐5.
Oyler DR, Parli SE, Bernard AC, et al. Nonopioid management of acute pain associated with trauma: focus on pharmacologic options. J Trauma Acute Care Surg 2015; 79(3): 475‐83.
Patanwala AE, Martin JR, Erstad BL. Ketamine for analgosedation in the intensive care unit: a systematic review. J Intens Care Med 2015.
Pieracci FM, Lin Y, Rodil M, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg 2016; 80(2): 187‐94.
Pressley CM, Fry WR, Philp AS, et al. Predicting outcome of patients with chest wall injury. Am J Surg 2012; 204(6): 910‐3.
Rostas JW, Lively TB, Brevard SB, et al. Rib fractures and their association with solid organ injury: higher rib fractures have greater significance for solid organ injury screening. Am J Surg 2016.
Sammy IA, Chatha H, Lecky F, et al. Are first rib fractures a marker for other life‐threatening injuries in patients with major trauma? A cohort study of patients on the UK trauma audit and research network database. Emerg Med J 2017; ePub ahead of print.
Sarani B, Schulte L, Diaz J. Pitfalls associated with open reduction and internal fixation of fractured ribs. Int J Care Injured 2015; 46: 2335‐40.
References
Slobogean GP, MacPherson CA, Sun T, et al. Surgical fixation vs nonoperative management of flail chest: a meta‐analysis. J Am Coll Surg 2013; 216(2): 302‐11.
Sullivan D, Lyons M, Montgomery R, et al. Exploring opioid‐sparing multimodal analgesia options in trauma: a nursing perspective. J Trauma Nurs 2016; 23(6): 361‐75.
Truitt MS, Murry J, Amos J, et al. Continuous intercostal nerve blockade for rib fractures: ready for primetime? J Trauma 2011; 71(6): 1548‐52.
Winters BA. Older Adults with traumatic rib fractures: an evidence based approach to their care. J Trauma Nurs 2009; 16(2): 93‐7.
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