Emergency Department Management of Rib Fractures (Trauma CME)

Table of Contents

 

About This Issue

Rib fractures that result from blunt thoracic trauma are painful injuries that can signal life-threatening cardiopulmonary injury, and quick recognition of the risk factors and optimal diagnostic imaging and treatment are essential to avoid significant morbidity and mortality. This issue reviews the most recent evidence on diagnosis and management of rib fractures, including the following:

How the history helps to form the patient’s risk profile, along with imaging, pain control, and disposition requirements

Using the NEXUS Chest Decision Instrument to determine the need for radiography, and using the NEXUS Chest CT Decision Instrument to determine the need for CT imaging

When chest radiography alone is sufficient, when CT is indicated, and when ultrasound can be useful

Opioids, NSAIDs, and acetaminophen are mainstays of pain management, but what is the evidence on using ketamine, gabapentin, methocarbamol, and lidocaine patches as adjuvant agents?

When ventilatory support is needed, an individualized approach is ideal, with a trial of noninvasive positive pressure ventilation or high-flow nasal cannula prior to initiating invasive ventilation

Recent evidence and guidelines on early operative fixation of acute rib fractures that point toward improved outcomes

Using the Battle score, Forced Vital Capacity pathway, or the RibScore Criteria tools to determine whether ICU admission is necessary

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Chest X-Ray
    2. Computed Tomography
    3. Ultrasound
    4. Laboratory Testing
11. Treatment
    1. Pain Management
       1. Oral, Intravenous, and Topical Pharmacological Treatments
          • Adjuvant Pharmacologic Pain Management Agents
       2. Regional and Neuraxial Analgesia
          • Ultrasound-Guided Regional Anesthesia
       3. Nonpharmacological Treatments
       4. Pain Management Summary
    2. Ventilatory Support
       1. Noninvasive Positive Pressure Ventilation
       2. High-Flow Nasal Cannula
       3. Invasive Mechanical Ventilation
       4. Summary of Ventilatory Support Options
    3. Operative Fixation of Acute Rib Fractures
    4. Treatment of Complications of Rib Fractures
12. Special Populations
13. Controversies and Cutting Edge
14. Disposition
15. Risk Management Pitfalls for Managing Rib Fractures in the Emergency Department
16. Summary
17. Time- and Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway for Emergency Department Management of Rib Fractures
20. Tables and Figures
    1. Table 1. American College of Radiology Appropriateness Criteria® for Chest Imaging after Minor Blunt Trauma Confined to the Chest
    2. Table 2. Ventilation Recommendations for Patients With Rib Fractures
    3. Table 3. Battle Score for Mortality Complications in Emergency Department Patients with Rib Fracture
    4. Table 4. RibScore Criteria
    5. Figure 1. Rib Cage Anatomy, Anterior View
    6. Figure 2. Pneumothorax on Chest X-Ray and Computed Tomography
    7. Figure 3. Ultrasound of a Normal Lung Versus an Injured Lung
    8. Figure 4. Kinesiotaping of Rib Fracture
    9. Figure 5. Emergency Department Rib Fracture Management Pathway According to Forced Vital Capacity
21. References

Abstract

Rib fractures resulting from blunt thoracic trauma are often associated with life-threatening complications of injury to cardiorespiratory systems. Given the risk for morbidity and mortality, the emergency clinician must be swift and thorough in diagnosing and managing these injuries. Society guidelines have been published to assist in determining best-practice approaches to pain control, imaging, and treatment. This issue reviews the recent studies and evidence for multimodal pain control, decision tools for diagnostic imaging, ventilatory support, and operative fixation. Scoring systems to determine disposition of patients are evaluated, with particular attention given to the special risks to the elderly patient.

Case Presentations

A 70-year-old man who fell down some stairs presents to the ED with severe chest pain…

• As you start your shift, your first patient is a 70-year-old man who fell while walking down a flight of stairs. He is complaining of severe pain around his right chest that is worse when breathing.
• The patient denies use of any blood thinners, recent illnesses, or pain or tenderness in any other location.
• Chest radiograph reveals simple rib fractures of ribs 4, 5, and 6, with no associated pneumothorax.
• The patient asks what can be done for his pain, and whether he is safe to go home…

A 21-year-old woman on her college crew team says she is experiencing pain in her upper chest when rowing…

• She says that her right upper chest has begun to hurt while rowing, and she is no longer able to participate in practice due to the pain.
• Imaging demonstrates a stress fracture at the site of the pain around her second rib, with no other injuries.
• She asks you how she should treat the injury, and whether she will be able to return to compete in the race next week…

EMS brings in a 45-year-old man who was in a motor vehicle crash, intubated, in respiratory distress…

• EMS reports that the patient was previously healthy, but they intubated him in the field after he demonstrated worsening signs of respiratory distress.
• Your complete trauma evaluation reveals a right-sided pneumothorax with flail chest.
• While speaking with the admitting intensive care unit team, you consider what kinds of treatment this patient might require for his injury…

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Clinical Pathway for Emergency Department Management of Rib Fractures

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * 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. 2017;82(3):618-626. (Meta-analysis; 22 studies, 986 patients) DOI: 10.1097/TA.0000000000001350

7. * Henry TS, Donnelly EF, Boiselle PM, et al. ACR Appropriateness Criteria(®) Rib Fractures. J Am Coll Radiol. 2019;16(5s):S227-s234. (Guidelines) DOI: 10.1016/j.jacr.2019.02.019

18. * Brasel KJ, Moore EE, Albrecht RA, et al. Western Trauma Association Critical Decisions in Trauma: management of rib fractures. J Trauma Acute Care Surg. 2017;82(1):200-203. (Practice guideline) DOI: 10.1097/TA.0000000000001301

20. * Witt CE, Bulger EM. Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol. Trauma Surg Acute Care Open. 2017;2(1):e000064. (Review) DOI: 10.1136/tsaco-2016-000064

21. * Galvagno SM Jr, 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):936-951. (Practice guideline) DOI: 10.1097/TA.0000000000001209

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Keywords: trauma, rib, fracture, cardiorespiratory, flail chest, pneumothorax, hemothorax, aorta, opioid, ketamine, gabapentin, regional anesthesia, binder, kinesiotaping, spirometer, NIPPV, HFNC, high-flow nasal cannula, fixation, Battle score

Points & Pearls Excerpt

• Within trauma literature, rib fractures are recognized as indicators of poor prognosis, particularly in elderly patients, patients with pathologic fractures, and patients with impending or ongoing respiratory failure as a result of their injury.
• Generally, injuries to ribs 1-3 suggest a higher-energy mechanism, because there is increased bone density and structural support.
• Most rib injuries from trauma occur in a midaxillary or posteroaxillary location.
• Stress fractures can occur in young and healthy patients from repetitive, low-impact exercise.
• Even minimal displacement from rib fractures can be associated with other injuries (lung, mediastinum, abdominal structures), and careful evaluation should be performed.