Management of Multiple Rib Fractures

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Original Date: 12/2013 | Last Review Date: 06/2019
Purpose: To standardize treatment of multiple rib fractures or flail chest.

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Definitions:

• Fracture displacement:
• • Undisplaced – >90% contact between the fracture cortical surfaces
  • Offset – some cortical contact between fracture surfaces, but less than 90%
  • Displaced – no cortical contact between fracture surfaces
•  Fracture type:
  • Simple – single fracture line across the rib with no fragmentation or comminution
  • Wedge – a wedge fracture has a second fracture line that does not span the whole width of the rib
  • Complex – at least two fracture lines with one or more fragments that span the width of the rib
• Series of fractures – fractures on neighboring ribs
• Anatomic locations of rib fractures:
  • Anterior – anterior to the anterior axillary line (vertical line from the intersection of the posterior border of the pectoralis major and the second rib)
  • Lateral – between anterior and posterior axillary lines
  • Posterior – posterior to the posterior axillary line (vertical line through the tip of the scapula)
• Flail segment – three of more consecutive ribs with two or more fractures in each rib without clinical paradoxical chest wall movement (i.e. radiographic flail)
• Flail chest – three or more consecutive ribs with two or more fractures in each rib with clinical paradoxical chest wall movement
• Ideal Body Weight (IBW):
  • Men: 50 kg + (2.3kg*(height in inches – 60))
  • Women: 45.5 kg + (2.3kg*(height in inches – 60))

Previously Stated Policies:

• Trauma patients being admitted to SIMU or with ≥ 2 rib fractures should be admitted to trauma service.

Indications for Admission to IMU:

• Age > 45 with a series of four or more fractures and/or flail segment or chest.(1)
• Any age with a series of fractures and/or flail segment or chest and:
  • • Poor pain control, or
    • Incentive spirometer (IS) volumes ≤ 15 cc/kg IBW, or
  • Oxygen requirement ≥ 5 L/min nasal cannula
  • Volume expansion protocol (VEP) desired every 2-3 hours (every 4 hours can be done on floor; <2 hours should be done in STICU)
• When the above indications are no longer met, the patient may be transferred to floor.

Indications for Admission to ICU:

• Mechanical ventilation
• VEP < q2 hours
• When the above indications are no longer met, the patient may be transferred to a lower level of care.

Initial Management for All Patients Admitted with a Series of Fractures:

• Multimodal pain therapy: https://med.uth.edu/surgery/acute-trauma-pain-multimodal-therapy/
• Volume expansion protocol:
  • Order in Care4: Respiratory Therapy Consult
  • Stepwise progression of therapy employed in the VEP:
    • Incentive spirometry in alert and cooperative patients.  If incentive spirometry goal is not achieved, positive expiratory pressure (PEP) is initiated
    • PEP (EzPAP®, MetaNeb®) is performed if patient is:
      • Unable to perform IS-or-
      • Not meeting incentive spirometry goal or
      • Has persistent or severe atelectasis or
      • Has poor oxygenation
    • Induced deep breathing in patients with a tracheostomy
  • Indications and frequency in the VEP – the RT will assess patient and assign them a RT Triage Score.  The frequency of VEP is based on the RT Triage Score:
    

    	RT Triage Score	VEP Frequency
    22-32	q4 hours and q2 hours prn
    15-21	QID and q4 hour prn
    8-14	TID and q4 hour prn
    0-7	BID and q4 hour prn
    Tracheotomies	q4 hour and q2 hour prn

  • Patients who meet incentive spirometry goals are discharged from the VEP.
  • Patients with ≥2 rib fractures, a pulmonary contusion, a chest tube, or abdominal/thoracic surgery who meet incentive spirometry goals are seen q shift if STICU/SIMU status and q 48 hours if floor status.
  • If you think patient with adequate incentive spirometry requires more frequent therapy than the VEP calls for, you may order “VEP q _ hour despite IS for __ hours duration.”
    • VEP can be done q4 on the floor at the most frequent.  A patient requiring more frequent treatments should be moved to SIMU or STICU.
• Physical activity:
  • If able, patient should be out of bed for majority of day (in chair and ambulating).
  • For patients who cannot get out of bed, the stationary hand bike may be used.
    • • Bike therapy should be used q4 hours during day time.
• Repeat CXR:
  • Patients with a series of fractures and/or flail segment should have a repeat CXR performed 24 hours after admission
  • If the 72-hour CXR shows any opacity concerning for a retained hemothorax, a non-contrast CT chest should immediately be obtained.
  • Clinical judgment should guide the decision to go for video assisted thoracoscopic surgery (VATS) and evacuation of hemothorax.  Ideally, the VATS would occur on hospital day 3 or 4.(2)
  • If the hemothorax is estimated to be less than 500 cc, observation may be considered.

Surgical stabilization of rib fractures (SSRF)

• Indications for SSRF at RDTI:
  • Flail segment
  • Flail chest
  • Series of five or more rib fractures
  • One or more rib displaced rib fracture
  • Unstable chest wall
  • Other non-empyema indication for VATS or thoracotomy, especially if fractures preclude stable chest closure
• Contraindications for SSRF at RDTI:
  • Spine injury which precludes the lateral decubitus position
  • Any skin, subcutaneous, or pleural infection (empyema)
  • Severe TBI with active ICP management
  • Uncorrected coagulopathy
  • Respiratory failure requiring advanced ventilator management, inverse ratio ventilation, or inhaled nitric oxide

Regional analgesia (see APPENDIX A)

• May provide superior pain control to multimodal pain regimen in patients with a series of rib fractures
• Consultation with Acute Pain Service is required
• Consider when:
  • Persistent incentive spirometer volumes < 15 cc/kg 24 hours after admission
  • Progression from spontaneous breathing to invasive mechanical ventilation or non-invasive positive pressure ventilation (NIPPV) within 48 hours of admission
  • Increasing FiO2 requirement within 48 hours of admission
  • Inability to wean from mechanical ventilation within 48 hours
  • Persistent pain score > 6 requiring continued IV opioids and/or IMU status 24 hours after admission.

APPENDIX A

Neuraxial techniques:

• Epidural analgesia (EA)
  • Associated with lower mortality and decreased pulmonary complications in patients older than 60 years(3)
  • Provides pain control that is superior to systemic (intravenous) opioids, enteral analgesics, and intrapleural analgesia(3-8)
  • Technically challenging
  • May be contraindicated in patients with unstable spine or pelvic fractures or those whose injuries preclude positioning for the procedure
  • Cannot be performed within 12 hours of enoxaparin administration, even at prophylactic doses
  • Complications include hypotension, spinal epidural hematoma, spinal cord injury
• Thoracic paravertebral nerve blockade (TPVB)
  • May provide a comparable improvement in pain control compared to EA(9)
  • Is technically easier to perform than EA
  • Can be used in patients with contraindications to EA
  • Complications include inadvertent epidural, intrathecal, or intrapleural injection, pneumothorax, hypotension, and vascular puncture

Non-neuraxial regional techniques:

• Technically easier to perform
• Not associated with hypotension
• Intercostal nerve blockade (ICNB)
  • Can provide improved pain control over a limited dermatome distribution(10)
  • Can be performed in patients with contraindications to EA
  • May require multiple injections for sufficient dermatomal coverage, which can increase the risk of local anesthetic toxicity
  • Complications include pneumothorax and vascular puncture
• Serratus plane block (SPB)
  • Newer technique, not well-studied
  • May provide improved pain control over a larger dermatome distribution than ICNB
  • Can be performed in patients with contraindications to EA
  • Complications include pneumothorax and vascular puncture