NUH Adult blunt chest trauma and rib fracture guideline

Transcription

1 NUH Adult blunt chest trauma and rib fracture guideline Full Title of Guideline: Author (include and role): Adult blunt chest wall trauma and rib fracture guideline Nottingham University Hospitals NHS Trust Nick Moody, Major Trauma clinical fellow, QMC, Chris Harber, Consultant Anaesthetist & Acute pain lead, QMC & City Campus Division & Speciality: Scope (Target audience, state if Trust wide): Review date (when this version 2020 goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive) Surgery, Major Trauma Trustwide These guidelines apply to all patients who sustain blunt blunt chest wall trauma. There is a separate spinal and epidural guideline for those requiring epidurals following rib fractures which should also be referred to. Change to patient pathway Change to admission to Major Trauma criteria Change to criteria for those requiring epidural Summary of evidence base this See references guideline has been created from: Ratification Group Consultation This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust.

2 Adult Blunt Chest Wall Trauma Guidelines Nottingham University Hospitals NHS Trust This guideline provides a framework for the assessment and management of adult patients with rib fractures following blunt chest wall trauma. This applies to all patients who are admitted with blunt chest wall trauma and may require a Major Trauma admission. These guidelines should be read in conjunction with the NUH Adult Epidural Guidelines. The relevant sections of these guidelines have been ratified by: Mr Adam Brooks Mr Ben Ollivere Dr Chris Harber Dr Craig Douglas Dr John Harris Consultant Trauma and HPB surgeon, MTC Director Consultant Orthopaedic Surgeon Consultant Anaesthetist & Acute Pain Lead Consultant Emergency Physician Consultant Anaesthetist

3 Introduction Blunt chest wall trauma is a cause of major morbidity and mortality in all age groups. The incidence in trauma can be up to 40%. The management of rib fractures are important due to the serious complications associated [1]. It occurs in a significant proportion of patients admitted to Major Trauma at Queens Medical Centre. Rib fractures may be isolated, particularly in the elderly with localised trauma, or may form part of the picture in a polytrauma patient with a number of different injuries [2]. Rib fractures can be associated with underlying pathology and injuries to various organs. Lung parenchymal damage can occur in the form of contusions, as well as pneumothorax and/or haemothorax. Liver and splenic injuries may also occur in conjunction with rib fractures [1, 2]. Pain from rib fractures can result in impaired ventilation, with an inability to properly deep breathe and cough causing splinting. In conjunction with the aforementioned lung contusions, this can lead to atelectasis, hypoxia and respiratory failure. Factors which result in an increased likelihood of complications following rib fractures include age, number of ribs fractured, presence of underlying lung pathology and preexisting use of anti-coagulant medications [1,2]. Thoracic epidural use has been widely shown to improve patient outcome following rib fractures. Epidural analgesia has been shown to result in shorter durations of mechanical ventilation, greater increase in tidal volumes and lower incidence of pneumonia when compared to intravenous (IV) or intramuscular (IM) analgesia [3]. This is the case even in those with more rib fractures who receive an epidural [3]. At Queens Medical Centre, the gold standard of analgesia in those with rib fractures is a Thoracic Epidural. Although the majority of rib fractures are not surgically fixed, and are not required to be, surgical fixation, particularly in flail chest injuries, is associated with a reduction in hospital acquired pneumonia, duration of mechanical ventilation, length of ITU stay, length hospital stay and incidence of chronic pain [4, 5, 6, 7, 8].

4

5

6

7

8 References 1. Sırmalı M. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J of Cardio-thoracic Surg 2003; 24: Battle et al. Predicting outcomes after blunt chest wall trauma: development and external validation of a newprognostic model. Crit Care 2014, 18:R9 3.. Jarvis AM, Cook CH, Lindsey DE, Reilley TE, Steinberg SM, Beery RM, Whitmill ML, Papadimos TJ, Stawicki SP. Comparison of epidural versus parenteral analgesia for traumatic rib fractures: A meta-analysis. OPUS 12 Scientist (3): Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, Lee G, Bailey M, Fitzgerald M. Prospective randomised controlled trial of operative rib fixation in traumatic flail chest. J Am CollSurg 2013 May 13;216(5): Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J ThoracCardiovasc Surg. 1995;110: Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization or internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52: Lafferty PM, Anavian J, Will RE, et al. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am. 2011; 93: Bottlang M, Walleser S, Noll M, et al. (2010) Biomechanical rationale and evaluation of an implant system for rib fracture fixation. European Journal of Trauma and Emergency Surgery 36(5):