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Intercostal Nerve Block. PAIN MEDICINE 2017. [DOI: 10.1007/978-3-319-43133-8_85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Maher L, Jayathissa S. Blunt chest trauma in a non-specialist centre: Right treatment, right place? Emerg Med Australas 2016; 28:725-729. [DOI: 10.1111/1742-6723.12680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/25/2016] [Accepted: 07/31/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Lesley Maher
- Intensive Care Unit; North Shore Hospital; Auckland New Zealand
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Posterior paramedian subrhomboidal analgesia versus thoracic epidural analgesia for pain control in patients with multiple rib fractures. J Trauma Acute Care Surg 2016; 81:463-7. [DOI: 10.1097/ta.0000000000001147] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Smoliga JM, Mohseni ZS, Berwager JD, Hegedus EJ. Common causes of dyspnoea in athletes: a practical approach for diagnosis and management. Breathe (Sheff) 2016; 12:e22-37. [PMID: 27408644 PMCID: PMC4933616 DOI: 10.1183/20734735.006416] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Key points Educational aims Dyspnoea during exercise is a common chief complaint in athletes and active individuals. It is not uncommon for dyspnoeic athletes to be diagnosed with asthma, “exercise-induced asthma” or exercise-induced bronchoconstriction based on their symptoms, but this strategy regularly leads to misdiagnosis and improper patient management. Dyspnoea during exercise can ultimately be caused by numerous respiratory and nonrespiratory conditions, ranging from nonpathological to potentially fatal in severity. As, such it is important for healthcare providers to be familiar with the many factors that can cause dyspnoea during exercise in seemingly otherwise-healthy individuals and have a general understanding of the clinical approach to this patient population. This article reviews common conditions that ultimately cause athletes to report dyspnoea and associated symptoms, and provides insight for developing an efficient diagnostic plan. Dyspnoea, fatigue and underperformance are often interrelated symptoms in athletes, and may have various causeshttp://ow.ly/4nsYnk
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Affiliation(s)
- James M Smoliga
- Dept of Physical Therapy, High Point University, High Point, NC, USA
| | - Zahra S Mohseni
- Dept of Biology, North Carolina State University, Raleigh, NC, USA
| | | | - Eric J Hegedus
- Dept of Physical Therapy, High Point University, High Point, NC, USA
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Cheng YJ. Lidocaine Skin Patch (Lidopat® 5%) Is Effective in the Treatment of Traumatic Rib Fractures: A Prospective Double-Blinded and Vehicle-Controlled Study. Med Princ Pract 2016; 25:36-9. [PMID: 26539836 PMCID: PMC5588305 DOI: 10.1159/000441002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 09/10/2015] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE The purpose of this study was to determine the efficacy of the Lidopat(®) 5% skin patch in relieving rib fracture pain. SUBJECTS AND METHODS From June 2009 to May 2011, 44 trauma patients with isolated rib fractures were enrolled in this study and randomized in a double-blind method into 2 groups. The experimental group (group E: 27 patients) used a Lidopat(®) 5% skin patch at the trauma site and took an oral analgesic drug for pain relief. The placebo group (group P: 17 patients) used a placebo vehicle patch and an oral analgesic drug. RESULTS The mean age, weight and hospital stay of patients were 56.8 ± 13.8 years, 67.4 ± 12.6 kg and 6.34 ± 1.3 days, respectively. In the first 4 days, there were no significant differences in pain scores between the groups (p > 0.05). After the 5th day, the average pain score was significantly less in group E (mean 1.5) than in group P (mean 3.10; p < 0.05). There was no significant difference in the number of fractured ribs between groups (p = 0.904). The use of meperidine and the length of hospital stay (6.0 vs. 6.9 days) were both significantly less in group E (p = 0.043 and 0.009, respectively). CONCLUSION In this study, the use of the Lidopat(®) 5% skin patch in patients with isolated rib fractures alleviated pain and shortened the hospital stay, and a lower dose of pain-relieving medication was used.
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Affiliation(s)
- Yu-Jen Cheng
- *Yu-Jen Cheng, Division of Thoracic Surgery, Department of Surgery, E-Da Hospital, Number 1, E-Da Road, Jiau-Shu Village, Yan-Chau District, Kaohsiung 824 (Taiwan), E-Mail
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Sareen A, Jain P, Pagare V. IMMEDIATE EFFECT OF KINESIOLOGY TAPING IN TREATING UNDISPLACED RIB FRACTURE PAIN. ACTA ACUST UNITED AC 2015. [DOI: 10.1142/s0218957715500104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Purpose: To determine the immediate effect of kinesiology taping in treating undisplaced rib fracture pain. Method: The study is a retrospective in which 10 Patients (5 females and 5 males) with 1 or 2 undisplaced middle rib fractured (5th, 6th, 7th) were included. The age group of the patients was 27–57 years. The diagnosis was made by the orthopedic surgeon and referred to Institute of Kinesiology Taping. Numeric pain rating scale readings were obtained and documented before and after the taping session. Results: A significant decrease in pain before and after the kinesiology taping was found both while deep breathing ([Formula: see text]0.001) and during coughing ([Formula: see text]0.001). The Mean[Formula: see text] S.D of NPRS reading in case of pre and post taping for deep breathing was 5.7[Formula: see text]0.95 and 4.4[Formula: see text]0.84, respectively and that for coughing was 7.2[Formula: see text]0.63 and 4.7[Formula: see text]1.16, respectively. Conclusion: Kinesiology taping has immediate effect in treating undisplaced middle rib fracture pain.
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Affiliation(s)
- Aarti Sareen
- Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune, India
| | - Piyush Jain
- Institute of Kinesiology Taping, Uttarpradesh, India
| | - Venus Pagare
- Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune, India
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Thoracic epidural analgesia in a child with multiple traumatic rib fractures. J Clin Anesth 2015; 27:685-91. [DOI: 10.1016/j.jclinane.2015.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 01/06/2015] [Accepted: 05/21/2015] [Indexed: 02/09/2023]
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Lee YJ, Lee SH, Choi HJ, Kim CS, Lim TH. WITHDRAWN: Comparison of the effectiveness in pain reduction between a rib splint produced in the ER and a manufactured rib splint: Pilot study. Am J Emerg Med 2015. [DOI: 10.1016/j.ajem.2015.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
BACKGROUND Traumatic rib fractures are associated with significant morbidity. Vital capacity (VC) assesses pulmonary function; however, limited data link VC to patient outcomes. Our objective was to determine if VC predicted complications and disposition in patients with rib fractures. METHODS This is a retrospective chart review of all patients with fractured ribs admitted to a Level 1 trauma center during a 4-year period. Patients were excluded if no VC was performed within 48 hours of admission. Data collected included demographics, hospital/intensive care unit length of stay, epidural, discharge to home versus extended care facility, mortality, chest Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), number of rib fractures, hemothorax/pneumothorax, presence of pulmonary contusion, presence of chest tube, chronic obstructive pulmonary disease, and average daily VC (percentage of predicted). Pulmonary complication was defined as pneumonia, need for intubation, new home O2 requirement, readmission for pulmonary issue, or intensive care unit transfer. Statistical analysis was performed using χ and multivariate logistic regression. RESULTS Of 801 patients with rib fractures, 683 had VC performed within 48 hours. Average age was 53 years, median ISS was 13 (interquartile range, 9-18), and median length of stay was 5 days. Most (72%) were discharged home, and 26% went to extended care facility. Ten percent developed a pulmonary complication, and there were nine deaths. Every 10% increase in VC was associated with 36% decrease in likelihood of pulmonary complication. Patients with a VC greater than 50% had a significantly lower association of pulmonary complication (p = 0.017), and a VC of less than 30% was independently associated with pulmonary complication (odds ratio, 2.36). CONCLUSION Patients with fractured ribs and VC of less than 30% have significant association for pulmonary complication. Higher VC is associated with lower likelihood of pulmonary complication. VC may help identify those at risk for complications after rib fractures, but a prospective study is necessary to confirm these findings. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV.
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Zaw AA, Murry J, Hoang D, Chen K, Louy C, Bloom MB, Melo N, Alban RF, Margulies DR, Ley EJ. Epidural Analgesia after Rib Fractures. Am Surg 2015. [DOI: 10.1177/000313481508101008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pain associated with rib fractures impairs respiratory function and increases pulmonary morbidity. The purpose of this study was to determine how epidural catheters alter mortality and complications in trauma patients. We performed a retrospective study involving adult blunt trauma patients with moderate-to-severe injuries from January 1, 2004 to December 31, 2013. During the 10-year period, 526 patients met the inclusion criteria; 43/526 (8%) patients had a catheter placed. Mean age of patients with epidural catheter (CATH) was higher compared with patients without epidural catheter (NOCATH) (54 vs 48 years, P = 0.021), Injury Severity Score was similar (26 CATH vs 27 NOCATH, P = 0.84), and CATH had higher mean rib fractures (7.4 vs 4.1, P < 0.001). Mortality was lower in CATH (0% vs 13%, P = 0.006). Deep vein thrombosis (DVT) rate was higher in CATH (12% vs. 5%, P = 0.036). After regression analysis, we found catheter placement to be a predictor for DVT (adjusted odds ratios 2.80, P = 0.036). Our center noted increased use of epidural catheters in patients who present with moderate-to-severe injuries. Patients with catheters were older and had a mean of 7.4 ribs fractured. The epidural cohort had longer hospital LOS and decreased mortality. In contrast to other studies, DVT rates were increased in patients who received epidural catheters.
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Affiliation(s)
- Andrea A. Zaw
- Division of Trauma and Critical Care, Department of Surgery
| | - Jason Murry
- Division of Trauma and Critical Care, Department of Surgery
| | - David Hoang
- Division of Trauma and Critical Care, Department of Surgery
| | - Kevin Chen
- Division of Trauma and Critical Care, Department of Surgery
| | - Charles Louy
- Department of Anesthesia, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Nicolas Melo
- Division of Trauma and Critical Care, Department of Surgery
| | | | | | - Eric J. Ley
- Division of Trauma and Critical Care, Department of Surgery
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DUCH P, MØLLER MH. Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials. Acta Anaesthesiol Scand 2015; 59:698-709. [PMID: 25683770 DOI: 10.1111/aas.12475] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 12/29/2014] [Indexed: 01/03/2023]
Abstract
BACKGROUND Traumatic rib fractures are a common condition associated with considerable morbidity and mortality. Observational studies have suggested improved outcome in patients receiving continuous epidural analgesia (CEA). The aim of the present systematic review of randomised controlled trials (RCTs) was to assess the benefit and harm of CEA compared with other analgesic interventions in patients with traumatic rib fractures. METHODS We performed a systematic review with meta-analysis and trial sequential analysis (TSA). Eligible trials were RCTs comparing CEA with other analgesic interventions in patients with traumatic rib fractures. Cumulative relative risks (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were estimated, and risk of systematic and random errors was assessed. The predefined primary outcome measures were mortality, pneumonia and duration of mechanical ventilation. RESULTS A total of six trials (n = 223) were included; all were judged as having a high risk of bias. In the conventional meta-analyses, there was no statistically significant difference in mortality (RR 2.18, 95% CI 0.21-22.42; P = 0.51; I(2) = 0%), duration of mechanical ventilation (MD -7.53, 95% CI -16.32 to 1.26; P = 0.09; I(2) = 91%) or pneumonia (RR 0.49, 95% CI 0.19-1.25; P = 0.13; I(2) = 0%) between CEA and other analgesic interventions. Subgroup analyses and sensitivity analyses, including TSA confirmed the results. CONCLUSION The quality and quantity of evidence for the use of CEA in patients with traumatic rib fractures is low, and there is no firm evidence for benefit or harm of CEA compared with other analgesic interventions. Well-powered RCTs with low risk of bias reporting clinically relevant patient-centred outcome measures are needed.
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Affiliation(s)
- P. DUCH
- Department of Anaesthesiology and Intensive Care Medicine; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
| | - M. H. MØLLER
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
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Unsworth A, Curtis K, Asha SE. Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery. Scand J Trauma Resusc Emerg Med 2015; 23:17. [PMID: 25887859 PMCID: PMC4322452 DOI: 10.1186/s13049-015-0091-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 01/07/2015] [Indexed: 11/23/2022] Open
Abstract
Blunt chest trauma is associated with a high risk of morbidity and mortality. Complications in blunt chest trauma develop secondary to rib fractures as a consequence of pain and inadequate ventilation. This literature review aimed to examine clinical interventions in rib fractures and their impact on patient and hospital outcomes. A systematic search strategy, using a structured clinical question and defined search terms, was performed in MEDLINE, EMBASE, CINAHL and the Cochrane Library. The search was limited to studies of adult humans from 1990-March 2014 and yielded 977 articles, which were screened against inclusion/exclusion criteria. A hand search was then performed of the articles that met the eligibility criteria, 40 articles were included in this review. Each article was assessed using a quantitative critiquing guideline. From these articles, interventions were categorised into four main groups: analgesia, surgical fixation, clinical protocols and other interventions. Surgical fixation was effective in patients with flail chest at improving patient outcomes. Epidural analgesia, compared to both patient controlled analgesia and intravenous narcotics in patients with three or more rib fractures improved both hospital and patient outcomes, including pain relief and pulmonary function. Clinical pathways improve outcomes in patients ≥ 65 with rib fractures. The majority of reviewed papers recommended a multi-disciplinary approach including allied health (chest physiotherapy and nutritionist input), nursing, medical (analgesic review) and surgical intervention (stabilisation of flail chest). However there was a paucity of evidence describing methods to implement and evaluate such multidisciplinary interventions. Isolated interventions can be effective in improving patient and health service outcomes for patients with blunt chest injuries, however the literature recommends implementing strategies such as clinical pathways to improve the care and outcomes of thesetre patients. The implementation of evidence-practice interventions in this area is scarce, and evaluation of interventions scarcer still.
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Affiliation(s)
- Annalise Unsworth
- Trauma Department, St George Hospital, Gray Street, Kogarah, NSW, 2217, Australia.
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia.
| | - Kate Curtis
- Trauma Department, St George Hospital, Gray Street, Kogarah, NSW, 2217, Australia.
- Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia.
| | - Stephen Edward Asha
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia.
- Department of Emergency, St George Hospital, Gray Street, Kogarah, NSW, 2217, Australia.
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Tianhong M, Yuxi Q, Zhimin W, Baili Y. Effect of Panax notoginseng in patients with multiple fractured ribs and pulmonary contusions caused by the 2008 Wenchuan earthquake. ACTA ACUST UNITED AC 2014; 21:360-4. [PMID: 25592947 DOI: 10.1159/000370011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to investigate whether the combination of conventional treatment and Panax notoginseng (PN group) is superior to conventional treatment alone (CG group) in reducing the clinical symptoms of patients with multiple fractured ribs and pulmonary contusions. PATIENTS AND METHODS We retrospectively analyzed the medical records of patients treated for multiple fractured ribs and pulmonary contusions with either conventional treatment (n = 17) or P. notoginseng (n = 18). Visual analog scale (VAS) pain scores and arterial oxygen saturation were measured at baseline and at 1 and 2 weeks following treatment. The duration of mechanical ventilation, systemic analgesics, and hospital stay were also recorded. RESULTS VAS scores in the PN group were lower than in the CG group at 1 week (p < 0.01) and at 2 weeks (p < 0.05). Arterial oxygen saturation in both groups was higher after treatment than at baseline (p < 0.05), but there was no statistically significant difference between the 2 groups (p > 0.05). The duration of mechanical ventilation, systemic analgesics administration, and hospital stay in the PN group was remarkably decreased as compared to the CG group (p < 0.05). CONCLUSION Combining conventional treatment and P. notoginseng seems to be an efficient method that can improve the clinical symptoms of multiple fractured ribs and pulmonary contusions.
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Affiliation(s)
- Ma Tianhong
- Orthopedics Department, Chengdu University of Traditional Chinese Medicine Hospital, Chengdu, Sichuan, China
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Comparison of anatomic landmarks and ultrasound guidance for intercostal nerve injections in cadavers. Reg Anesth Pain Med 2014; 38:503-7. [PMID: 24121611 DOI: 10.1097/aap.0000000000000006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Intercostal nerve (ICN) injections are routinely performed under anatomic landmark or fluoroscopic guidance for acute and chronic pain indications. Ultrasound (US) is being used increasingly to perform ICN injections, but there is lack of evidence to support categorically the benefits of US over conventional techniques. We compared guidance with US versus anatomic landmarks for accuracy and safety of ICN injections in cadavers in a 2-phase study that included evaluation of deposition of injected dye by dissection and spread of contrast on fluoroscopy. METHODS A cadaver experiment was performed to validate US as an imaging modality for ICN blocks. In the first phase of the study, 12 ICN injections with 2 different volumes of dye were performed in 1 cadaver using anatomic landmarks on one side and US-guidance on the other (6 injections on each side). The cadaver was then dissected to evaluate spread of the dye. The second phase of the study consisted of 74 ICN injections (37 US-guided and 37 using anatomic landmarks) of contrast dye in 6 non-embalmed cadavers followed by fluoroscopy to evaluate spread of the contrast dye. RESULTS In the first phase of the study, the intercostal space was identified with US at all levels. Injection of 2 mL of dye was sufficient to ensure compete staining of the ICN for 5 of 6 US-guided injections but anatomic landmark guidance resulted in correct injection at only 2 of 6 intercostal spaces. No intravascular injection was found on dissection with either of the guidance techniques. In the second phase of the study, US-guidance was associated with a higher rate of intercostal spread of 1 mL of contrast dye on fluoroscopy compared with anatomic landmarks guidance (97% vs 70%; P = 0.017). CONCLUSIONS Ultrasound confers higher accuracy and allows use of lower volumes of injectate compared with anatomic landmarks as a guidance method for ICN injections in cadavers. Ultrasound may be a viable alternative to anatomic landmarks as a guidance method for ICN injections.
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Mohta M, Ophrii EL, Sethi AK, Agarwal D, Jain BK. Continuous paravertebral infusion of ropivacaine with or without fentanyl for pain relief in unilateral multiple fractured ribs. Indian J Anaesth 2014; 57:555-61. [PMID: 24403614 PMCID: PMC3883389 DOI: 10.4103/0019-5049.123327] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Continuous thoracic paravertebral block (TPVB) provides effective analgesia for unilateral multiple fractured ribs (MFR). However, prolonged infusion of local anaesthetic (LA) in high doses can predispose to risk of LA toxicity, which may be reduced by using safer drugs or drug combinations. This study was conducted to assess efficacy and safety of paravertebral infusion of ropivacaine and adrenaline with or without fentanyl to provide analgesia to patients with unilateral MFR. Methods: Thirty adults, having ≥3 unilateral MFR, with no significant trauma outside chest wall, were studied. All received bolus of 0.5% ropivacaine 0.3 ml/kg through paravertebral catheter, followed by either 0.1-0.2 ml/kg/hr infusion of ropivacaine 0.375% with adrenaline 5 μg/ml in group RA or ropivacaine 0.2% with adrenaline 5 μg/ml and fentanyl 2 μg/ml in group RAF. Rescue analgesia was provided by IV morphine. Results: Statistical analysis was performed using unpaired Student t-test, Chi-square test and repeated measures ANOVA. After TPVB, VAS scores, respiratory rate and PEFR improved in both groups with no significant inter-group differences. Duration of ropivacaine infusion, morphine requirements, length of ICU and hospital stay, incidence of pulmonary complications and opioid-related side-effects were similar in both groups. Ropivacaine requirement was higher in group RA than group RAF. No patient showed signs of LA toxicity. Conclusion: Continuous paravertebral infusion of ropivacaine 0.375% with adrenaline 5 μg/ml at 0.1-0.2 ml/kg/hr provided effective and safe analgesia to patients with unilateral MFR. Addition of fentanyl 2 μg/ml allowed reduction of ropivacaine concentration to 0.2% without decreasing efficacy or increasing opioid-related side-effects.
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Affiliation(s)
- Medha Mohta
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Emeni L Ophrii
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Ashok Kumar Sethi
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Deepti Agarwal
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - Bhupendra Kumar Jain
- Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
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The effect of epidural placement in patients after blunt thoracic trauma. J Trauma Acute Care Surg 2014; 76:39-45; discussion 45-6. [DOI: 10.1097/ta.0b013e3182ab1b08] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Long-term outcomes after blunt injury to the boney thorax: an integrative literature review. J Trauma Nurs 2013; 20:56-64; quiz 65-6. [PMID: 23459434 DOI: 10.1097/jtn.0b013e318286629b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Management of blunt injury to the boney thorax centers on the hospital; yet, these injuries continue to impact patients long after hospitalization. The purpose of this literature review was to identify long-term outcomes associated with this injury. A literature search found 616 studies and, after screening, yielded 6 articles for review. Patient and injury characteristics and postinjury assessment findings were explored. The impact of this injury can be prolonged and life altering, prompting the need for further investigation. A greater understanding of injury-specific posthospitalization outcomes could elucidate the impact of these injuries on patients, families, and society.
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Daoust R, Émond M, Bergeron É, LeSage N, Camden S, Guimont C, Vanier L, Chauny JM. Risk factors of significant pain syndrome 90 days after minor thoracic injury: trajectory analysis. Acad Emerg Med 2013; 20:1139-45. [PMID: 24238316 DOI: 10.1111/acem.12248] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 06/17/2013] [Accepted: 06/20/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective was to identify the risk factors of clinically significant pain at 90 days in patients with minor thoracic injury (MTI) discharged from the emergency department (ED). METHODS A prospective, multicenter, cohort study was conducted in four Canadian EDs from November 2006 to November 2010. All consecutive patients aged 16 years or older with MTI were eligible at discharge from EDs. They underwent standardized clinical and radiologic evaluations at 1 and 2 weeks, followed by standardized telephone interviews at 30 and 90 days. A pain trajectory model characterized groups of patients with different pain evolutions and ascertained specific risk factors in each group through multivariate analysis. RESULTS In this cohort of 1,132 patients, 734 were eligible for study inclusion. The authors identified a pain trajectory that characterized 18.2% of the study population experiencing clinically significant pain (>3 of 10) at 90 days after a MTI. Multivariate modeling found two or more rib fractures, smoking, and initial oxygen saturation below 95% to be predictors of this group of patients. CONCLUSIONS To the authors' knowledge, this is the first prospective study of trajectory modeling to detect risk factors associated with significant pain at 90 days after MTI. These factors may help in planning specific treatment strategies and should be validated in another prospective cohort.
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Affiliation(s)
- Raoul Daoust
- The Emergency Department; Hôpital du Sacré-Coeur de Montréal; Université de Montréal; Montréal Québec
| | - Marcel Émond
- The Emergency Department; Hôpital Enfant-Jésus de Québec; Université Laval; Québec Québec
| | - Éric Bergeron
- The Surgery Department; Hôpital Charles Lemoyne; Longueuil Québec
| | - Natalie LeSage
- The Emergency Department; Hôpital Enfant-Jésus de Québec; Université Laval; Québec Québec
| | - Stéphanie Camden
- The Unité de Recherche en Traumatologie-Médecine D'urgence-Soins Intensifs; Hôpital de l'Enfant-Jésus; Québec Québec
| | - Chantal Guimont
- The Emergency Department; Centre Hospitalier Universitaire de l'Université Laval; Québec Québec Canada
| | - Laurent Vanier
- The Emergency Department; Hôpital Charles Lemoyne; Longueuil Québec
| | - Jean-Marc Chauny
- The Emergency Department; Hôpital du Sacré-Coeur de Montréal; Université de Montréal; Montréal Québec
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Use of ketorolac is associated with decreased pneumonia following rib fractures. Am J Surg 2013; 207:566-72. [PMID: 24112670 DOI: 10.1016/j.amjsurg.2013.05.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 05/15/2013] [Accepted: 05/30/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND The effectiveness of the nonsteroidal anti-inflammatory drug ketorolac in reducing pulmonary morbidity after rib fractures remains largely unknown. METHODS A retrospective cohort study was conducted spanning January 2003 to June 2011 assessing pneumonia within 30 days and potential adverse effects of ketorolac among all patients with rib fractures who received ketorolac <4 days after injury compared with a random sample of those who did not. RESULTS Among 202 patients who received ketorolac and 417 who did not, ketorolac use was associated with decreased pneumonia (odds ratio, .14; 95% confidence interval, .04 to .46) and increased ventilator-free days (difference, 1.8 days; 95% confidence interval, 1.1 to 2.5) and intensive care unit-free days (difference, 2.1 days; 95% confidence interval, 1.3 to 3.0) within 30 days. The rates of acute kidney injury, gastrointestinal hemorrhage, and fracture nonunion were not different. CONCLUSIONS Early administration of ketorolac to patients with rib fractures is associated with a decreased likelihood of pneumonia, without apparent risks.
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Bradley M, Okoye O, DuBose J, Inaba K, Demetriades D, Scalea T, O'Connor J, Menaker J, Morales C, Shiflett T, Brown C. Risk factors for post-traumatic pneumonia in patients with retained haemothorax: results of a prospective, observational AAST study. Injury 2013; 44:1159-64. [PMID: 23433600 DOI: 10.1016/j.injury.2013.01.032] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 01/11/2013] [Accepted: 01/19/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Retained haemothorax (RH) is a problematic sequela of thoracic trauma, reported in up to 20% of patients following chest injury. RH is associated with a higher severity of thoracic trauma and may portend the onset of other serious post-traumatic complications, including pneumonia. The development of pneumonia has previously been reported to be as high as 19.5% in the setting of traumatic RH. The purpose of this study was to identify risk factors for the development of pneumonia as a complication in RH. METHODS We utilized the American Association for the Surgery of Trauma Post-Traumatic Retained Haemothorax database. Patients with post-traumatic RH were prospectively enrolled from 2009 to 2011. Inclusion criteria were placement of a thoracostomy tube within 24h of admission for the evacuation of pneumothorax or haemothorax and subsequent chest computed tomography scan chest showing RH. Patients treated with thoracotomy before placement of tube thoracostomy were excluded. For univariate analysis, the Chi-square test with Yates correction was used for comparison of categorical risk factors and the Student's t-test or the Mann-Whitney test for comparison of continuous risk factors. To identify independent risk factors for the development of pneumonia, variables from the univariate analysis significant at p<0.2 were entered into a forward logistic regression model. Adjusted odds ratio and 95% confidence intervals (CI) were derived. RESULTS 328 patients with post-traumatic RH from 20 United States centres were enrolled. After stepwise regression analysis, ISS>25 (adjusted OR: 7.1; 95% CI: 3.1, 16.4; p<0.001), blunt mechanism of injury (adjusted OR: 3.5; 95% CI: 1.7, 7.2; p=0.001), and failure to administer peri-procedural antibiotics on the initial thoracostomy tube placement (adjusted OR: 2.6; 95% CI: 1.30, 5.4; p=0.01) were found to be independent predictors of the pneumonia in patients with post-traumatic RH. CONCLUSIONS To our knowledge, our current study is the largest attempt to identify the independent predictors for pneumonia in this population. Our data show that elevated ISS, blunt thoracic trauma, and failure to administer peri-procedural antibiotics on tube thoracostomy placement are the statistically significant independent risk factors.
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Affiliation(s)
- Matthew Bradley
- Department of Trauma and Surgical Critical Care, University of Maryland Medical System/R Adams Cowley Shock Trauma, Baltimore, MD 21201, USA.
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Abstract
Blunt chest wall trauma accounts for a large proportion of all trauma presentations to the Emergency Departments in the United Kingdom and has a high reported incidence of morbidity and mortality. The difficulty in the assessment and management of this patient group arises from the possibility that the patient may develop potentially life-threatening complications up to approximately 72 h post-injury, even in patients who have sustained what is initially considered a minor injury. Limited consensus currently exists in the literature regarding optimal assessment or management strategies for this patient group. The aim of this review is to provide an overview of current research investigating the optimal assessment and management strategies for the blunt chest wall trauma patient.
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Affiliation(s)
- Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea, UK
- College of Medicine, Swansea University, Swansea, UK
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Chiumello D, Coppola S, Froio S, Gregoretti C, Consonni D. Noninvasive ventilation in chest trauma: systematic review and meta-analysis. Intensive Care Med 2013; 39:1171-80. [PMID: 23571872 DOI: 10.1007/s00134-013-2901-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 03/09/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE Single studies of Noninvasive Ventilation (NIV) in the management of acute respiratory failure in chest trauma patients have produced controversial findings. The aim of this study is to critically review the literature to investigate whether NIV reduces mortality, intubation rate, length of stay and complications in patients with chest trauma, compared to standard therapy. METHODS We performed a systematic review and meta-analysis of randomized controlled trials, prospective and retrospective observational studies, by searching PubMed, EMBASE and bibliographies of articles retrieved. We screened for relevance studies that enrolled adults with chest trauma who developed mild to severe acute respiratory failure and were treated with NIV. We included studies reporting at least one clinical outcome of interest to perform a meta-analysis. RESULTS Ten studies (368 patients) met the inclusion criteria and were included for the meta-analysis. Five studies (219 patients) reported mortality and results were quite homogeneous across studies, with a summary relative risk for patients treated with NIV compared with standard care (oxygen therapy and invasive mechanical ventilation) of 0.26 (95 % confidence interval 0.09-0.71, p = 0.003). There was no advantage in mortality of continuous positive airway pressure over noninvasive pressure support ventilation. NIV significantly increased arterial oxygenation and was associated with a significant reduction in intubation rate, in the incidence of overall complications and infections. CONCLUSIONS These results suggest that NIV could be useful in the management of acute respiratory failure due to chest trauma.
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Affiliation(s)
- D Chiumello
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
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Murata H, Salviz EA, Chen S, Vandepitte C, Hadzic A. Ultrasound-Guided Continuous Thoracic Paravertebral Block for Outpatient Acute Pain Management of Multilevel Unilateral Rib Fractures. Anesth Analg 2013; 116:255-7. [DOI: 10.1213/ane.0b013e31826f5e25] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Critically ill patients are routinely provided analgesia and sedation to prevent pain and anxiety, permit invasive procedures, reduce stress and oxygen consumption, and improve synchrony with mechanical ventilation. Regional preferences, patient history, institutional bias, and individual patient and practitioner variability, however, create a wide discrepancy in the approach to sedation of critically ill patients. Untreated pain and agitation increase the sympathetic stress response, potentially leading to negative acute and long-term consequences. Oversedation, however, occurs commonly and is associated with worse clinical outcomes, including longer time on mechanical ventilation, prolonged stay in the intensive care unit, and increased brain dysfunction (delirium and coma). Modifying sedation delivery by incorporating analgesia and sedation protocols, targeted arousal goals, daily interruption of sedation, linked spontaneous awakening and breathing trials, and early mobilization of patients have all been associated with improvements in patient outcomes and should be incorporated into the clinical management of critically ill patients. To improve outcomes, including time on mechanical ventilation and development of acute brain dysfunction, conventional sedation paradigms should be altered by providing necessary analgesia, incorporating propofol or dexmedetomidine to reach arousal targets, and reducing benzodiazepine exposure.
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Hakim SM, Latif FS, Anis SG. Comparison between lumbar and thoracic epidural morphine for severe isolated blunt chest wall trauma: a randomized open-label trial. J Anesth 2012; 26:836-44. [PMID: 22674157 DOI: 10.1007/s00540-012-1424-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 05/23/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this randomized, parallel-arm, open-label trial was to compare lumbar versus thoracic epidural morphine for severe isolated blunt chest wall injury as regards the incidence of pulmonary complications and pain control. METHODS Fifty-five patients who sustained severe isolated blunt chest wall trauma were randomized using a computer-generated list to receive epidural morphine injection every 24 h through an epidural catheter inserted into the lumbar (n = 28) or thoracic (n = 27) region. Need for mechanical ventilation, incidence of pneumonia, arterial blood gas values, and pulmonary function tests were compared in both groups. Pain scores, supplemental analgesic consumption, length of intensive care unit (ICU) stay, and occurrence of epidural morphine-related side effects were compared as well. Primary outcome measures were need for mechanical ventilation and incidence of pneumonia. RESULTS Five (17.9 %) patients in the lumbar group were mechanically ventilated, compared with six (22.2 %) in the thoracic group (hazard ratio 1.35; 95 % CI 0.41-4.4; P = 0.611). Seven (25 %) patients in the lumbar group developed pneumonia versus six (22.2 %) in the thoracic group (hazard ratio 0.97; 95 % CI 0.33-2.9; P = 0.96). Both groups were comparable as regards the duration of mechanical ventilation (P = 0.141) and length of ICU stay (P = 0.227). Pain scores, supplemental analgesic consumption, pulmonary function, and occurrence of epidural morphine-related side effects were, likewise, comparable (P > 0.05). CONCLUSION Lumbar and thoracic epidural morphine administered as once-daily injection to patients with severe isolated blunt chest wall trauma were comparable in terms of pain control, incidence of pulmonary complications, and occurrence of epidural morphine-related side effects.
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Affiliation(s)
- Sameh Michel Hakim
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
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79
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Continuous Intercostal Nerve Blockade for Rib Fractures: Ready for Primetime? ACTA ACUST UNITED AC 2011; 71:1548-52; discussion 1552. [DOI: 10.1097/ta.0b013e31823c96e0] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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80
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Zink KA, Mayberry JC, Peck EG, Schreiber MA. Lidocaine patches reduce pain in trauma patients with rib fractures. Am Surg 2011; 77:438-42. [PMID: 21679552 DOI: 10.1177/000313481107700419] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rib fracture pain is notoriously difficult to manage. The lidocaine patch is effective in other pain scenarios with an excellent safety profile. This study assesses the efficacy of lidocaine patches for treating rib fracture pain. A prospectively gathered cohort of patients with rib fracture was retrospectively analyzed for use of lidocaine patches. Patients treated with lidocaine patches were matched to control subjects treated without patches. Subjective pain reports and narcotic use before and after patch placement, or equivalent time points for control subjects, were gathered from the chart. All patients underwent long-term follow-up, including a McGill Pain Questionnaire (MPQ). Twenty-nine patients with lidocaine patches (LP) and 29 matched control subjects (C) were analyzed. During the 24 hours before patch placement, pain scores and narcotic use were similar (LP 5.3, C 4.6, P = 0.19 and LP 51, C 32 mg morphine, P = 0.17). In the 24 hours after patch placement, LP patients had a greater decrease in pain scores (LP 1.2, C 0.0, P = 0.01) with no change in narcotic use (LP -8.4, C 0.5-mg change in morphine, P = 0.25). At 60 days, LP patients had a lower MPQ pain score (LP 7.7, C 12.2, P < 0.01), although only one patient was still using a patch. There was no difference in time to return to baseline activity (LP 73, C 105 days, P = 0.16) and no adverse events. Lidocaine patches are a safe, effective adjunct for rib fracture pain. Lidocaine patches resulted in a sustained reduction in pain, outlasting the duration of therapy.
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Affiliation(s)
- Karen A Zink
- Division of Trauma, Critical Care, & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon 97239, USA
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81
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Lucas SD, Higdon T, Boezaart AP. Unintended epidural placement of a thoracic paravertebral catheter in a patient with severe chest trauma. PAIN MEDICINE 2011; 12:1284-9. [PMID: 21714843 DOI: 10.1111/j.1526-4637.2011.01180.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Severe pain can lead to ventilatory compromise in patients with multiple rib fractures. Regional anesthetic techniques, including continuous thoracic paravertebral and thoracic epidural blocks, can be useful in reducing this pain and subsequent morbidity due to respiratory compromise. Thoracic paravertebral block can result in significant complications. Presumed epidural spread of injected medication has been described with thoracic paravertebral block. High-quality radiographic images of an attempted placement of a thoracic paravertebral catheter in the epidural space have not been reported. We present these images to highlight the occurrence of this complication. SETTINGS AND PATIENTS In this case, we report an attempted placement of a thoracic paravertebral catheter that passed into the epidural space. High-fidelity, three-dimensional computer tomography images and the management of the unintended epidural catheterization are presented. RESULTS AND CONCLUSIONS In the setting of severe chest trauma, the potential risk of unintended placement of an intended thoracic paravertebral catheter in the epidural space is graphically illustrated as a potential risk of this procedure.
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Affiliation(s)
- Stephen D Lucas
- Department of Anesthesiology, Division of Regional Anesthesiology and Perioperative Pain Medicine, University of Florida College of Medicine, Gainesville, Florida 32610-0254, USA.
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Miraflor E, Chuang K, Miranda MA, Dryden W, Yeung L, Strumwasser A, Victorino GP. Timing is everything: delayed intubation is associated with increased mortality in initially stable trauma patients. J Surg Res 2011; 170:286-90. [PMID: 21550060 DOI: 10.1016/j.jss.2011.03.044] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 02/24/2011] [Accepted: 03/17/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The indications for immediate intubation in trauma are not controversial, but some patients who initially appear stable later deteriorate and require intubation. We postulated that initially stable, moderately injured trauma patients who experienced delayed intubation have higher mortality than those intubated earlier. METHODS Medical records of trauma patients intubated within 3 h of arrival in the emergency department at our university-based trauma center were reviewed. Moderately injured patients were defined as an ISS < 20. Early intubation was defined as patients intubated from 10-24 min of arrival. Delayed intubation was defined as patients intubated ≥25 min after arrival. Patients requiring immediate intubation, within 10 min of arrival, were excluded. RESULTS From February 2006 to December 2007, 279 trauma patients were intubated in the emergency department. In moderately injured patients, mortality was higher with delayed intubation than with early intubation, 11.8% versus 1.8% (P = 0.045). Patients with delayed intubations had greater frequency of rib fractures than their early intubation counterparts, 23.5% versus 3.6% (P = 0.004). Patients in the delayed intubation group had lower rates of cervical gunshot wounds than the early intubation group, 0% versus 10.7% (P = 0.048) and a trend toward fewer of skull fractures 2.9% versus 16.1%, (P = 0.054). CONCLUSIONS These findings suggest that delayed intubation is associated with increased mortality in moderately injured patients who are initially stable but later require intubation and can be predicted by the presence of rib fractures.
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Affiliation(s)
- Emily Miraflor
- Department of Surgery, UCSF-East Bay, Alameda County Medical Center, Oakland 94602, California, USA
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83
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Chelly JE, Ghisi D, Fanelli A. Continuous peripheral nerve blocks in acute pain management. Br J Anaesth 2011; 105 Suppl 1:i86-96. [PMID: 21148658 DOI: 10.1093/bja/aeq322] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The indications for continuous nerve blocks for the perioperative pain management in hospitalized and ambulatory patients have extended well beyond orthopaedics. These techniques are not only used to control pain in patients undergoing major upper and lower extremity surgery, but also to provide perioperative analgesia in patients undergoing abdominal, plastic, urological, gynaecological, thoracic, and trauma surgeries. Infusion regimens of local anaesthetics and supplements must take into consideration the condition of the patient before and after surgery, the nature and intensity of the surgical stress associated with the surgery, and the possible need for immediate functional recovery. Continuous nerve blocks have proved safe and effective in reducing opioid consumption and related side-effects, accelerating recovery, and in many patients reducing the length of hospital stay. Continuous nerve blocks provide a safer alternative to epidural analgesia in patients receiving thromboprophylaxis, especially with low molecular-weight heparin.
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Affiliation(s)
- J E Chelly
- Division of Regional Anesthesia and Acute Interventional Perioperative Pain Service, Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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84
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Marhofer P, Kettner S, Hajbok L, Dubsky P, Fleischmann E. Lateral ultrasound-guided paravertebral blockade: an anatomical-based description of a new technique. Br J Anaesth 2010; 105:526-32. [DOI: 10.1093/bja/aeq206] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Santana-Rodríguez N, Clavo B, Fernández-Pérez L, Rivero JC, Travieso MM, Fiuza MD, Villar J, García-Castellano JM, Hernández-Pérez O, Déniz A. Pulsed ultrasounds accelerate healing of rib fractures in an experimental animal model: an effective new thoracic therapy? J Thorac Cardiovasc Surg 2010; 141:1253-8. [PMID: 20708756 DOI: 10.1016/j.jtcvs.2010.06.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 05/18/2010] [Accepted: 06/20/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Rib fractures are a frequent traumatic injury associated with a relatively high morbidity. Currently, the treatment of rib fractures is symptomatic. Since it has been reported that pulsed ultrasounds accelerates repair of limb fractures, we hypothesized that the application of pulsed ultrasounds will modify the course of healing in an animal model of rib fracture. METHODS We studied 136 male Sprague-Dawley rats. Animals were randomly assigned to different groups of doses (none, 50, 100, and 250 mW/cm(2) of intensity for 3 minutes per day) and durations (2, 10, 20, and 28 days) of treatment with pulsed ultrasounds. In every subgroup, we analyzed radiologic and histologic changes in the bone callus. In addition, we examined changes in gene expression of relevant genes involved in wound repair in both control and treated animals. RESULTS Histologic and radiologic consolidation was significantly increased by pulsed ultrasound treatment when applied for more than 10 days. The application of 50 mW/cm(2) was the most effective dose. Only the 100 and 250 mW/cm(2) doses were able to significantly increase messenger RNA expression of insulin-like growth factor 1, suppressor of cytokine signaling-2 and -3, and vascular endothelial growth factor and decrease monocyte chemoattractant protein-1 and collagen type II-alpha 1. CONCLUSIONS Our findings indicate that pulsed ultrasound accelerates the consolidation of rib fractures. This study is the first to show that pulsed ultrasound promotes the healing of rib fractures. From a translational point of view, this easy, cheap technique could serve as an effective new therapeutic modality in patients with rib fractures.
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Affiliation(s)
- Norberto Santana-Rodríguez
- Experimental Surgery Unit, Research Unit, Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain.
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86
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Nirula R, Mayberry JC. Article Commentary: Rib Fracture Fixation: Controversies and Technical Challenges. Am Surg 2010. [DOI: 10.1177/000313481007600820] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rib fractures are a common injury affecting more than 350,000 people each year in the United States and are associated with respiratory complications, prolonged hospitalization, prolonged pain, long-term disability, and mortality. The social and economic costs that rib fractures contribute to the health care burden of the United States are therefore significant. But despite this measurable impact on patients’ quality of life, current treatment of the majority of patients in the United States with rib fracture syndromes is supportive only. Even the most severe of chest wall injuries have historically been treated non-operatively. Recently, however, several reports from American centers support an increased application of operative fixation. With this resurgent interest of American surgeons in mind, we review the clinical presentations, potential indications, controversies, and technical challenges unique to rib fracture fixation.
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Affiliation(s)
- Raminder Nirula
- Department of Surgery, Burns/Trauma/Critical Care Section, University of Utah, Salt Lake City, Utah
| | - John C. Mayberry
- Department of Surgery, Trauma/Critical Care/Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
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Out with the Old, In with the New: A Novel Approach to Treating Pain Associated with Rib Fractures. World J Surg 2010; 34:2359-62. [DOI: 10.1007/s00268-010-0651-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kim HY, Kim MY. Management of Patients with Rib Fractures: Analysis of the Risk Factors Affecting the Outcome. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.3.285] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Han Yong Kim
- Department of Thoracic and Cardiovascular Surgery, Masan Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Myoung Young Kim
- Department of Thoracic and Cardiovascular Surgery, Masan Samsung Hospital, Sungkyunkwan University School of Medicine
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90
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Ultrasound-Guided Interventional Procedures in Pain Medicine: A Review of Anatomy, Sonoanatomy, and Procedures. Reg Anesth Pain Med 2009; 34:458-74. [DOI: 10.1097/aap.0b013e3181aea16f] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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91
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92
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Prospective, Randomized Comparison of Continuous Thoracic Epidural and Thoracic Paravertebral Infusion in Patients With Unilateral Multiple Fractured Ribs—A Pilot Study. ACTA ACUST UNITED AC 2009; 66:1096-101. [DOI: 10.1097/ta.0b013e318166d76d] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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93
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Gil S, Pascual J, Villazala R, Madrazo M, González F, Bernal G. [Continuous perfusion of ropivacaine plus fentanyl for nerve-stimulator-guided paravertebral thoracic block to manage pain for a man with multiple rib fractures]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:257-259. [PMID: 19537271 DOI: 10.1016/s0034-9356(09)70385-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
MESH Headings
- Accidents, Traffic
- Adult
- Amides/administration & dosage
- Analgesia, Epidural
- Anesthetics, Local/administration & dosage
- Autonomic Nerve Block/methods
- Chest Pain/drug therapy
- Chest Pain/therapy
- Drug Therapy, Combination
- Electric Stimulation Therapy
- Electrodes, Implanted
- Fentanyl/administration & dosage
- Fractures, Closed/physiopathology
- Fractures, Open/physiopathology
- Fractures, Open/surgery
- Humans
- Hypoxia/etiology
- Male
- Narcotics/administration & dosage
- Pain, Postoperative/drug therapy
- Pain, Postoperative/therapy
- Rib Fractures/physiopathology
- Ropivacaine
- Sternum/injuries
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94
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Luyet C, Eichenberger U, Greif R, Vogt A, Szücs Farkas Z, Moriggl B. Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: an imaging study. Br J Anaesth 2009; 102:534-9. [PMID: 19244265 DOI: 10.1093/bja/aep015] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND During paravertebral block, the anterolateral limit of the paravertebral space, which consists of the pleura, should preferably not be perforated. Also it is possible that, during the block, the constant superior costotransverse ligament can be missed in the loss-of-resistance technique. We therefore aimed to develop a new technique for an ultrasound-guided puncture of the paravertebral space. METHODS We performed 20 punctures and catheter placements in 10 human cadavers. A sonographic view showing the pleura and the superior costotransverse ligament was obtained with a slightly oblique scan using a curved array transducer. After inline approach, injection of 10 ml normal saline confirmed the correct position of the needle tip, distended the space, and enabled catheter insertion. The spread of contrast dye injected through the catheters was assessed by CT scans. RESULTS The superior costotransverse ligament and the paravertebral space were easy to identify. The needle tip reached the paravertebral space without problems under visualization. In contrast, the introduction of the catheter was difficult. The CT scan revealed a correct paravertebral spread of contrast in 11 cases. Out of the remaining, one catheter was found in the pleural space, in six cases there was an epidural, and in two cases there was a prevertebral spread of contrast dye. CONCLUSIONS We successfully developed a technique for an accurate ultrasound-guided puncture of the paravertebral space. We also showed that when a catheter is introduced through the needle with the tip lying in the paravertebral space, there is a high probability of catheter misplacement into the epidural, mediastinal, or pleural spaces.
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Affiliation(s)
- C Luyet
- Department of Anaesthesiology and Pain Therapy, Inselspital, University Hospital of Bern, and University of Bern, CH-3010 Bern, Switzerland
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95
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Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2009; 56:230-42. [DOI: 10.1007/s12630-009-9052-7] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Revised: 11/03/2008] [Accepted: 01/05/2009] [Indexed: 12/19/2022] Open
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96
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Abstract
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.
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Affiliation(s)
- Zaffer Qasim
- Emergency and Critical Care Medicine, Salford Royal Hospitl NHS Foundation Trust, Salford M6 8HD, UK
| | - Carl Gwinnutt
- Department of Anaesthesia, Salford Royal Hospital NHS Foundation Trust, Salford M6 8HD UK,
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Tornero Tornero JC, Gómez Gómez M, Fabregat Cid G, Aliaga Font L, Roqués Escolar V, Escamilla Cañete B, Guerrí Cebollada A. [Complications after regional anesthesia]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2008; 55:552-562. [PMID: 19086723 DOI: 10.1016/s0034-9356(08)70652-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
In recent years, there has been a considerable increase in the number of procedures carried out under regional anesthesia. The techniques used can be associated with a number of complications, which should be understood so that they can be recognized and managed appropriately. The overall incidence of reported complications associated with these techniques is low and therefore, with currently available data, we can only have an approximate idea of their incidence. The objective of this study is to systematically describe the complications that may arise from the use of neuraxial and peripheral regional anesthesia techniques.
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98
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Thoracic Paravertebral Block (TPVB): Use in Managing Complications of Multiple Rib Fractures. Reg Anesth Pain Med 2008. [DOI: 10.1097/00115550-200809001-00475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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99
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Abstract
BACKGROUND Historic advances in combat prehospital care have been made in the last decade. Unlike other areas of critical care, most of these innovations are not the result of significant improvements in technology, but by conceptual changes in how care is delivered in a tactical setting. The new concept of Tactical Combat Casualty Care has revolutionized the management of combat casualties in the prehospital tactical setting. DISCUSSION The Tactical Combat Casualty Care concept recognizes the unique epidemiologic and tactical considerations of combat care and that simply extrapolating civilian care concepts to the battlefield are insufficient. SUMMARY This article examines the most recent and salient advances that have occurred in battlefield prehospital care driven by our ongoing combat experience in the Iraq and Afghanistan and the evolution around the Tactical Combat Casualty Care concept.
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100
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Reduction of rib fractures with a bioresorbable plating system: preliminary observations. ACTA ACUST UNITED AC 2008; 64:1264-9. [PMID: 18469648 DOI: 10.1097/ta.0b013e3180340e31] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Operative fixation of rib fractures can reduce morbidity and mortality. Currently, resorbable fixation devices are used in a variety of surgical procedures. METHODS A standard osteotomy was prepared in 30 New Zealand white rabbits at the 12th rib. Eighteen had surgical repair with bioresorbable plates and 12 underwent nonoperative management. Half the animals in each group were killed at 3-week postfracture and the remaining animals were killed at 6-week postfracture. Ribs were radiographed and processed histologically to assess fracture healing. Rib reduction was defined as the alignment of the rib ends in a structural condition similar to the prefractured state and quantitative radiomorphometry measured the radiopaque callus surrounding the rib injury sites. Statistical analysis was performed using Fisher's exact test and an unpaired Student's t test and significance was established at p < 0.05. RESULTS At both the 3- and 6-week intervals, seven of the nine rib fractures remained reduced in the operative group, whereas zero of six and three of six of the rib fractures remained reduced, respectively, in the nonoperative group. A statistically significant increase in radiopaque callus surrounding the rib injury sites was observed at 3 and 6 weeks in the fixed groups. CONCLUSIONS Fixation of rib fractures with a bioresorbable miniplate system was superior to nonoperative treatment at the 3-week interval, with a statistically significant increase in radiopaque callus formation at both 3 and 6 weeks. Additional studies will evaluate the biomechanical outcomes and degradation tissue response after extended in vivo intervals.
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