Epidural versus intravenous pain control in elderly patients with rib fractures

Flail chest: pathophysiology and management

Thoracic trauma is an important cause of morbidity and mortality in the UK, frequently found in drivers of motor vehicles following high-speed accidents. One of the more serious injuries is a flail chest, particularly when there are also underlying pulmonary contusions. For many years the optimal therapeutic regimen for the management of this condition has remained somewhat controversial. More recently, the role of epidural analgesia, the use of non-invasive techniques of ventilation and identification of those who may benefit from surgical stabilisation have been more clearly defined.

Geriatric Trauma

Elderly trauma patients present unique challenges and face more significant obstacles to recovery than younger patients. Despite overall higher mortality, longer length of stay, increased resource use, and higher rates of discharge to rehabilitation, most elderly trauma patients return to independent or preinjury functional status. Critical to improving these outcomes is an understanding that although similar trauma principles apply to the elderly, these patients require more aggressive evaluation and resuscitation. This article reviews the recent developments in the literature regarding care of the elderly trauma patient.

Vital Capacity as a Predictor of Outcome in Elderly Patients with Rib Fractures

BACKGROUND

This study tests the relationships between early bedside vital capacity (VC) measurement and morbidity, mortality, and resource consumption in geriatric blunt chest trauma patients with rib fractures.

METHODS

This was a retrospective study examining all patients > or = 65 years old with rib fractures who had a VC measured within 48 hours of their emergency department evaluation. Outcome variables included pulmonary complications, death from pulmonary complications, hospital length of stay (LOS), intensive care unit length of stay (ICU LOS), and discharge disposition.

RESULTS

Thirty-eight patients met the study criteria. The mean age was 80.2 (+/-7.4) years, the mean number of rib fractures was 3.6 (+/-1.6), and the mean ISS was 6.9 (+/-4.7). VC and the percentage of the predicted vital capacity (pVC) were both inversely correlated with LOS (p = 0.0076 and p = 0.0172, respectively). Linear regression analysis suggested that patients with a VC < 1.4 L or < 55% of their pVC had a LOS > 3 days. Mean VC was 36% higher in patients who were discharged home versus those discharged to an extended care facility (ECF; p = 0.025). There was a trend toward significance when comparing VC to ICU LOS (p = 0.079), but none in predicting pulmonary complications (p = 0.3299). No correlations between VC and mortality can be drawn given the single death in the cohort.

CONCLUSIONS

Bedside VC is a simple measurement which could predict LOS in elderly patients with rib fractures and may identify those patients requiring ECF upon discharge. Further prospective study may highlight the utility of emergency room VC in determining the disposition of these patients.