Jay A. Yelon and Fred A. Luchette (eds.)Geriatric Trauma and Critical Care201410.1007/978-1-4614-8501-8_24
© Springer Science+Business Media New York 2014
24. Chest Wall Injury
(1)
Department of Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, 359796, Seattle, WA 98104-2499, USA
Abstract
Elderly patients are at increased risk for chest wall injuries including rib and sternal fractures. In addition, these patients have increased morbidity and mortality related to these injuries when compared to younger patients. The purpose of this chapter is to review the current literature regarding the patterns of chest wall injury in the geriatric population, evaluate the factors contributing to worse outcome, and discuss injury prevention and management strategies for patients with these injuries.
Introduction
Thoracic injury accounts for up to 25 % of fatalities among injured patients. Chest wall injuries are common with rib fractures identified in approximately 10–26 % of patients presenting to a trauma center and sternal fractures in <1 % [1–3]. Elderly patients are at increased risk for both rib and sternal fractures when compared to younger patients [4, 5]. Several studies have reported that these injuries are associated with increased morbidity and mortality in this patient cohort [4, 6–10]. The purpose of this chapter is to review the current literature regarding the patterns of chest wall injury in the geriatric population, evaluate the factors contributing to worse outcome, and discuss injury prevention and management strategies for patients with these injuries.
Epidemiology
A recent report from the National Trauma Data Bank noted that 9 % of patients in this database carried a diagnosis of one or more rib fractures with an overall mortality rate of 10 % [1]. The incidence of rib fractures in the elderly has been reported at 60 per 100,000 persons per year [11]. Elderly patients are thought to be at greater risk for rib fractures due to loss of cortical bone mass, which allows the bones to fracture with less kinetic energy than is required in younger patients. In the study by Bergeron et al., more than 50 % of elderly patients presenting with rib fractures had suffered a fall from standing [6]. The second most common etiology is motor vehicle crashes (MVC). A recent report from the Crash Injury Research and Engineering Network (CIREN) database noted that the majority of rib and sternal fractures occurring in elderly patients following MVCs result from compression of the thorax by the seat belt system [5]. They suggest that with the increasing number of elderly drivers, attention should be paid to the design of these safety systems relative to the increased fragility of older patients.
Several studies report increased morbidity and mortality among older patients subjected to chest wall injury compared to a younger cohort. Most studies evaluating disparity in outcome between younger and older patients focus on the population >65 years of age; however, some studies have noted impaired outcome beginning at age 45 [8]. Mortality reports range from 2 to 22 % and are likely heavily influenced by inclusion of patients with multisystem injury. Bulger et al. reported that mortality for elderly patients (>65 years) was more than twofold higher than the younger cohort (22 % vs. 10 %) [7]. The risk of mortality increased 19 % and the risk of pneumonia by 27 % for each additional rib fracture. Several others have noted increased morbidity with increasing number of ribs fractures. A recent meta-analysis, which evaluated the risk factors associated with poor outcome, reported a combined odds ratio for mortality of 1.98 (95 % CI: 1.86–2.11) for age >65 years and 2.02 (95% CI: 1.89–2.15) for three or more rib fractures [12]. Another report noted a significant increase in mortality for 6 or more fractured ribs [1].
Another contributing factor to impaired outcome in the elderly is likely the increased rate of associated medical comorbidities. Bergeron et al. reported a nearly threefold increased risk of mortality for patients with a preexisting medical condition (OR 2.98, 95 % CI 1.1–8.3) [6]. In a recent multicenter study, focusing on elderly patients with isolated blunt chest injury, 19.9 % of patients had coexisting coronary artery disease, 13.5 % lung disease, and 7.1 % congestive heart failure [13]. Preexisting congestive heart failure was one of the strongest predictors of mortality in this series. Similarly, Brasel et al. reported an adjusted odds ratio of 2.62 (95 % CI:1.93–3.55) for mortality following blunt chest trauma in patients with congestive heart failure [14].
The primary complication which develops in these patients after hospitalization is pneumonia. Pneumonia rates vary depending on the population studied. For the entire population hospitalized with one or more rib fractures, the rate of pneumonia is reported to be 6 % [14]. However, when one reviews patients admitted to a trauma center, reports range from 11 to 17 % for patients younger than 65 years to 31–34 % for patients older than 65 years [6, 7]. Bulger et al. reported that elderly patients had a risk of pneumonia exceeding 30 % [7]. The impact of pneumonia on mortality is debated. Bergeron noted a nearly fourfold increase in mortality risk for patients who developed a pneumonia (OR 3.8 (95 % CI: 1.5–9.7) [6]. However, Brasel et al. reported that pneumonia was associated with increased mortality among those with no associated injuries but was not a major factor for those with multisystem injury [14]. Regardless, the development of pneumonia has been associated with increased duration of mechanical ventilation and prolonged ICU stay, thus significantly impacting the resources required to care for these patients.
Injury Prevention
The leading causes of chest wall injury in the elderly are falls and motor vehicle crashes. There are several programs which have been proposed for elderly fall prevention which are beyond the scope of this review. However, recent data also supports consideration for specific injury prevention strategies associated with chest wall fractures resulting from motor vehicle collisions. Bansal et al. reported an analysis of 287 elderly patients with rib and sternal fractures after MVCs and noted that the primary source of these injuries in frontal impacts was compression from the seat belts or contact with the rim of the steering wheel [5]. For side impact crashes, contact with the side interior (door panel) was the primary etiology. For seat belt-related injuries, they suggest that a four-point safety belt system or wider shoulder straps may allow more even distribution of the force to the chest and thus have the potential to reduce these injuries. For side impact crashes, advances in side airbags/torso bags should be investigated. The use of “elderly,” more fragile, crash test dummies might be needed to test these innovations.
Treatment
Hospital Admission
The first question to address in the management of elderly patients with rib fracture is which patients will benefit from hospital admission. This is an issue for the elderly patient with isolated chest wall injury, which can occur after even a minor fall from standing. Several authors have advocated that based on the increased risk of poor outcome in this patient cohort, patients over age 65 with >3 rib fractures should be admitted to the hospital and those with >6 rib fractures should be admitted to an intensive care unit for monitoring even without evident respiratory compromise on admission [10].
Pain Management
The cornerstone of management for multiple rib fractures is attention to pain control. Patients with inadequate pain control will minimize their chest wall motion by reducing their tidal volume and coughing and as a result are at significant risk of developing nosocomial pneumonia. The options for initial inpatient pain control include intravenous narcotics and regional anesthetics. These may be supplemented with injectable or oral NSAIDS as indicated, with eventual transition to oral narcotics prior to discharge. There have been a number of studies, which have investigated pain control strategies for these patients. These are discussed for each option below. Regardless of the approach selected, involving a dedicated pain relief service to monitor the effectiveness of the strategy chosen is critical. Development of a multidisciplinary pathway for management of these patients has been associated with improved outcome [15–17]. Todd et al. recently reported on a pathway for patient with four or more rib fractures over the age of 45 years [15]. In this study pathway patients were monitored closely for pain and cough scores and incentive spirometry volume. Based on this assessment a pain service was consulted to optimize pain control, respiratory therapy was consulted for a volume expansion protocol, physical therapy was consulted to increase patient mobility, and attention was paid to nutritional support and medical comorbidities. Patients managed with this clinical pathway were found to have a shorter ICU and hospital stay and lower mortality.
Oral Pain Medications
Oral narcotics are generally reserved for patients with minimal rib fractures who may be managed as outpatients. Patients on intravenous or regional medications may be transitioned to oral agents several days after injury in anticipation of discharge. Nonsteroidal anti-inflammatory drugs may be given in concert with narcotics to reduce the opioid need, although there are no studies specific to rib fracture pain management. NSAID use is limited by bleeding concerns and potential renal toxicity, so should be avoided in trauma patients with significant early bleeding risk, such as ongoing hemothorax or solid organ injury, and in those with renal insufficiency.
Intravenous Narcotics
Intravenous narcotics are usually the first method of pain control employed for patients with multiple rib fractures. This route of administration is preferred over subcutaneous or intramuscular injection, as the onset of action is more rapid and more predictable. Patients must be closely monitored for excessive sedation or depression of respiratory drive, especially among the elderly. Patient-controlled analgesia is a good option for patients who are alert as they can control the delivery of the medication, which may provide a more timely response and diminish excessive sedation. Excessive sedation of elderly patients is associated with a significant increased risk of aspiration, which can further compromise pulmonary function. Thus, for patients who are particularly sensitive to narcotics, regional analgesia regimen should be considered.
Regional Anesthetics
There are several approaches to the administration of regional anesthetics/narcotics. These include continuous epidural infusion of local anesthetics and/or narcotics, paravertebral or intrapleural infusion of local anesthetic, intermittent intercostal nerve blocks, and continuous local anesthetic infusion in the subcutaneous space following thoracotomy.
The most widely studied approach is the use of epidural catheters for infusion of local anesthetics, with or without narcotics. Previous studies have shown that the use of epidural catheters results in improved pulmonary function tests and better pain scores when compared to intravenous narcotics [18–22]. These studies have generally included all adults and have not focused specifically on the elderly population. In the trial by Bulger et al., patients were randomized to receive intravenous narcotics vs. epidural catheter. There was a significant reduction in the risk of pneumonia and a 2-day reduction in the average duration of mechanical ventilation for the epidural group [23]. A recent systematic review of the literature failed to identify a clear impact of epidural analgesia on mortality or ICU length of stay, but did suggest a benefit on the duration of mechanical ventilation [24]. Use of epidural catheters for pain control after severe blunt chest wall injury is a Level 1 recommendation in the 2004 EAST guidelines [25].
Epidural catheter use is limited in some cases due to the many contraindications to catheter placement in patients with multisystem injury. The most common contraindications are associated spine fractures and coagulopathy. In a recent survey of pain service directors at major trauma centers in the USA, it was evident that there remains considerable controversy in this area and better definition of the absolute and relative contraindications is needed to weigh against the potential benefit of this approach [26]. A common side effect of epidural infusion is systemic hypotension, which thus mandates close monitoring especially in the elderly patient population. One retrospective series noted a higher rate of complications among elderly patients receiving epidural analgesia; however, this analysis was limited due to significant differences in the baseline characteristics between the treatment groups [27].
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
