Trauma Surgeons Gone Wild: Sternal & Rib Fractures, and Blunt Cardiac Injury

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Nurses Edition Commentary

Mel Herbert, MD MBBS FAAEM, Lisa Chavez, RN, and Kathy Garvin, RN
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Nathan M. -

I had a discussion with one of my colleges about an old lady who fell a few days prior and had three ribs fractures, no pneumothorax or contusion. Her pain was controlled and I was sending her home. What are your comments about the teaching: old + 3 or more rib fractures = admission? I thought it applied to more significant trauma.

I think your probably going to address this in the next segment, but I've always thought that rib fractures causing a pneumonia was a myth. A cardiac contusion sounds more likely. I've surveyed a few docs about whether they send their patients home with incentive spirometry. It seems that most don't do it. I searched for evidence and couldn't find much. Any thoughts?

Nathan M. -

I mean "colleagues" and "you're"

Daniel S., MD -

great review with this. Only issue that have is that there was no mention (even from Mel) about prevention of atelectasis and pneumonia. My old CT surgery attending drilled into my head that all patients have to cough or deep breath. Instruction on splinting with a pillow and more importantly the cheap and effective incentive spirometer. I send all patients home (even those with bruised ribs) with an incentive spirometer.

Rabbott -

Remember that ultrasound is easy to use, quick, and sensitive for finding sternal fractures.

Henry A., -

two questions for the commentator:
1.what are the indications(if any) for a rib series. I was taught that a CXR is the test needed (to r/o hemo/pneumo or other series pathology) . Whether the ribs are bruised or broken...still treated symptomatically)

2. in general for relatively minor trauma,when is a CT Chest indicated (beyond a plain film)

great discussion...Thanks

Mizuho S. -

FROM KENJI INABA:

These are really great points that Nathan and Daniel brought up.

Rib fractures cause pain, which then results in changes to the local pulmonary dynamics (from splinting) as well as systemic immobility, which then leads to all of the negative downstream effects. With the force required to break ribs, there is the additive impact of the underlying pulmonary contusion. This impairs pulmonary gas exchange, which can progress as the area of contusion increases and inflammatory changes occur.

The decision to admit has to be individualized and should take into consideration things such as age, frailty, co-morbidities, extent of chest wall trauma and home situation. I agree that simple rules of thumb, taking into account only age and number of rib fractures, lack the ability to discriminate between those that can be safely discharged home and those that will need to be admitted.

The data on Incentive Spirometry in this scenario as pointed out by both Nathan and Daniel is very limited and although we use IS liberally in patients who have been admitted, a clear outcome improvement has not been shown. They are however very inexpensive and may help, so no harm in prescribing them. The mainstay of treatment however is pain control and this really should be the focus of your treatment. If the patient's pain can be adequately treated as an outpatient, discharge may be appropriate. If the patient pain cannot be adequately controlled, or there are other reasons for admission such as associated injuries or lack of caregiver support at home, these patients should be admitted.

Hope that makes sense, Kenji

SD -

What qualifies for a normal and abnormal EKG in this context? Anything outside of dysrythmia or ischemia?

Kenji I. -


Hi Henry, great comments. Yes, I agree that the standard chest imaging would be a CXR, which will detect the presence or absence of a HTx or PTx. Any extensive rib fracturing will also be seen on the CXR. As you state however, the critical factor is not whether or not there is a rib fracture or the number of fractures but rather, the amount of pain, the effect of the pain on pulmonary mechanics and the patient’s frailty and ability to tolerate the pain. Therefore, like yourself, I do not utilize the “rib series”.

After blunt trauma, acutely, the chest CT is utilized primarily for two reasons. First, it is the test of choice for the thoracic aorta. For any patients with a mediastinal abnormality or any other surrogate CXR findings suggestive of a blunt thoracic aortic injury, a CT should be ordered. Using CT as a screening modality to look for an occult thoracic aortic injury in the “high energy mechanism” patient with an adequate and normal CXR is very controversial and remains unresolved. For the relatively minor trauma you describe however, obtaining a chest CT to examine the thoracic aorta would be of low yield. The second reason for a chest CT is to characterize the extent of any PTx, HTx or pulmonary contusion. Again, for the relatively minor trauma you describe, the chest CT would be of low yield and all of the clinical decision making could likely be done on the basis of the physical examination and CXR. Hope that helps, Kenji

Kenji I. -

Great question regarding the EKG. I assume this is the initial screening EKG for blunt cardiac injury…if so, yes, any abnormality other than sinus tachycardia would constitute a positive screening EKG. There is a nice summary of this issue in the review published by Raid Yousef and John Carr in The Annals of Thoracic Surgery, Volume 98, Issue 3, September 2014, Pages 1134-1140 “Blunt Cardiac Trauma: A Review of the Current Knowledge and Management”. Hope that helps, Kenji

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