Rib Fracture: Guidelines and Pathways

Educational Objectives

The goal of this program is to improve the management of rib fractures. After hearing and assimilating this program, the clinicians will be better able to:

1. Implement a multimodal regimen for pain management in patients with rib fractures.

Summary

Rib fractures: management is critical as it affects patients on many levels; nearly 50% of these patients require intensive care unit (ICU) management, and ≈33% develop pulmonary complications; multiple rib fractures in elderly persons are associated with increased mortality and complications; a burden to the health care system and a disruptive injury; no universal nomenclature for assessment and communication of chest wall injuries exists; rib fracture taxonomy has evolved as there is now a surgical solution; Van Wijck et al (2022) reported strong interobserver reliability on location of rib fractures, but not on type and displacement of the fractures; Todd et al (2006) found that implementing a multidisciplinary clinical pathway reduced lengths of ICU and hospital stays, complications, and mortality; most early pathways looked at pain and physical therapy or occupational therapy consultation; however, there was no clarity on where patients should be admitted, where to discharge, when to operate, and optimal age cutoffs

Rib Injury Guidelines (RIG): include various parameters (eg, age, incentive spirometry, comorbidities, pain score, cough) that are added to produce a score; RIG scores <2 indicate hospital discharge, scores 3 to 9 indicate hospital admission, and scores >9 require ICU admission; found to reduce ICU admissions by ≈50%; validated and safe, reliable, and cost-effective; RIG is available for all to use

Multimodal pain management: Burton et al (2022) looked at different pathways for nonopioid and opioid agents and found that implementing a multimodal pain regimen reduced overall opioid use and overall outpatient opioid use; if pain is not controlled with opioids, regional analgesia can be used; epidural anesthesia is the gold standard and is associated with few complications but has a high failure rate for pain control; regional blocks (eg, erector spinae plane block, serratus anterior plane block, paravertebral blocks) are also used; no recommendation on using epidural vs nonepidural regional anesthesia exists

Surgical rib fixation: has been used since the early 2000s; flail chest is associated with mortality, need for tracheostomy, and increased duration of mechanical ventilation; makes a difference in management of flail chest; Dehghan et al (2022) looked at unstable chest wall injuries (with or without flail chest) and found that rib fixation helped reduce overall mortality but did not change much in terms of complications and days on the ventilator; Pieracci et al (2020) found that overall pain score, quality of life, narcotic consumption, and complications were reduced in patients with nonflail rib fractures who had rib fixation; Van Wijck et al (2022) classified pulmonary contusions as mild, moderate, and severe and found that rib fixation makes a difference in patients with mild and severe pulmonary contusions; the Chest Wall Injury Society has guidelines to contraindications and indications for fixation; if performed, fixation should be done within 72 hr from injury

Readings

Burton SW, Riojas C, Gesin G, et al; PRIMUM Group. Multimodal analgesia reduces opioid requirements in trauma patients with rib fractures. J Trauma Acute Care Surg. 2022 Mar 1;92(3):588-596. doi: 10.1097/TA.0000000000003486. PMID: 34882599; PMCID: PMC8866226; Dehghan N, Nauth A, Schemitsch E, et al; Canadian Orthopaedic Trauma Society and the Unstable Chest Wall RCT Study Investigators. Operative vs nonoperative treatment of acute unstable chest wall injuries: A randomized clinical trial. JAMA Surg. 2022 Nov 1;157(11):983-990. doi: 10.1001/jamasurg.2022.4299. PMID: 36129720; PMCID: PMC9494266; Pieracci FM, Leasia K, Bauman Z, et al. A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL). J Trauma Acute Care Surg. 2020 Feb;88(2):249-257. doi: 10.1097/TA.0000000000002559. PMID: 31804414; Pieracci FM, Schubl S, Gasparri M, et al. The Chest Wall Injury Society recommendations for reporting studies of surgical stabilization of rib fractures. Injury. 2021;52(6):1241-1250. doi:10.1016/j.injury.2021.02.032; Todd SR, McNally MM, Holcomb JB, et al. A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. Am J Surg. 2006 Dec;192(6):806-11. doi: 10.1016/j.amjsurg.2006.08.048. PMID: 17161098; Van Wijck SFM, Curran C, Sauaia A, et al. Interobserver agreement for the Chest Wall Injury Society taxonomy of rib fractures using computed tomography images. J Trauma Acute Care Surg. 2022;93(6):736-742. doi:10.1097/TA.0000000000003766; Van Wijck SFM, Pieracci FM, Smith EF, et al. Rib fixation in patients with severe rib fractures and pulmonary contusions: Is it safe?. J Trauma Acute Care Surg. 2022 Dec 1;93(6):721-726. doi: 10.1097/TA.0000000000003790. Epub 2022 Sep 19. PMID: 36121283; PMCID: PMC9671593.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Joseph was recorded at Mattox Vegas Trauma, Critical Care & Acute Care Surgery 2023, held March 27-29, 2023, in Las Vegas, NV, and presented by Trauma and Critical Care Foundation. For information about upcoming CME activities from this presenter, please visit https://www.trauma-criticalcare.com. Audio Digest thanks the speaker and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.25 CE contact hours.

Lecture ID:

GS710702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.