Comparison between lumbar and thoracic epidural morphine for severe isolated blunt chest wall trauma: a randomized open-label trial

Comparative efficacy of therapeutics for traumatic musculoskeletal pain in the emergency setting: A network meta-analysis

OBJECTIVE

Musculoskeletal pain control is essential in the management of trauma patients in the emergency department (ED). Here, we performed a network meta-analysis of the use of analgesics to manage traumatic musculoskeletal pain.

METHOD

This network meta-analysis (NMA) protocol was registered in PROSPERO (CRD42020150145). Electronic databases were searched for randomized controlled trials comparing systemic pharmaceutical interventions for treating traumatic musculoskeletal pain in the ED setting. The outcomes were global efficacy and changes in pain intensity.

RESULTS

Eighteen studies (2656 patients, four medication classes) met the inclusion criteria. The top-ranking medication class for global efficacy was nonsteroidal anti-inflammatory drugs (NSAIDs; network odds ratio: 0.52, 95% credible interval: 0.34-0.81, surface under the cumulative ranking curve score: 86). No interventions were more effective at decreasing pain intensity than opioids at 60 min.

CONCLUSION

NSAIDs were the most effective medications for treating traumatic musculoskeletal pain, and combination therapies may not have advantages in the ED setting.

Assessing outcome measures used after rib fracture: A COSMIN systematic review

PURPOSE

The incidence of invasive treatment of rib fracture has increased significantly over the last decade however the evidence of improved patient outcomes to support this is lacking. A systematic review was performed to identify patient reported outcome measures (PROMs) used in the assessment of outcomes following chest wall injury. The quality of evidence for the psychometric properties of the identified PROMs was graded using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology.

METHODS

Rib fracture studies measuring patient reported outcomes were identified using PubMed/Medline, EMBASE, AMED and PsycINFO. Methodological quality of measurement properties was evaluated with the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist.

RESULTS

A total of 64 studies were identified including 19 different PROM instruments. Domains included in the reported PROMs included pain, breathlessness, general health quality of life, physical function and physiological health. No rib fracture specific PROM was identified. The most frequently reported instrument was the SF-36 reporting overall quality of life (HRQoL) although there was very low quality evidence for its content validity. There was low quality evidence to support good content validity for the Medical Research Council (MRC) dyspnoea scale, Brief Pain Index (BPI) and McGill Pain Questionnaire (MPQ). No PROM had undergone validation in a rib fracture population. The overall quality of the PROM development studies was poor. While we were unable to identify a clear "gold standard", based on the limited current evidence, we recommend that the EQ-5D-5L is used in combination with the MRC and BPI or MPQ for future rib fracture studies.

CONCLUSION

The lack of validated outcome measures for rib fracture patients is a significant limitation of the current literature. Further studies are needed to provide validated outcome measures to ensure accuracy of the reported results and conclusions. As interventions for rib fractures have become more common in both research and clinical practice this has become an urgent priority.

Predictors of Dependency in Geriatric Trauma Patients with Rib Fractures: A Population Study

The geriatric trauma population is unique. These patients are at risk of being discharged to rehabilitation or a skilled nursing facility, instead of being returned to their homes, placing a significant burden on both the patient families and society. This study evaluated which patient characteristics increase the likelihood of a previously independent geriatric blunt trauma becoming functionally dependent and being discharged to a location other than home. Data were extracted from the National Trauma Data Bank from 2012 to 2014 for blunt trauma patients ≥65 years old, admitted from home, with one or more rib fractures. Primary outcomes were discharge home versus a facility. Subgroup analysis evaluated disposition to acute short-term rehabilitation or subacute rehabilitation or skilled nursing facility. Multivariable analysis was used to calculate probabilities of disposition based on the above variables, controlling for comorbidities. Sixteen thousand six hundred thirty-two patients were included. Only 58 per cent were discharged home. Increased age, ≥4 rib fractures, white race, and female gender were found to increase the risk of discharge to a facility. In addition, patients with chronic renal failure, history of diabetes, obesity, or heart failure were less likely to be discharged home. This study shows that age, gender, race, and the number of rib fractures are statistically significant in predicting which patients are less likely to be discharged home. This reinforces the need for the development of triage and treatment protocols in this higher risk population, to decrease the social and financial burden of these injuries.

Development of a blunt chest injury care bundle: An integrative review

BACKGROUND

Blunt chest injuries (BCI) are associated with high rates of morbidity and mortality. There are many interventions for BCI which may be able to be combined as a care bundle for improved and more consistent outcomes.

OBJECTIVE

To review and integrate the BCI management interventions to inform the development of a BCI care bundle.

METHODS

A structured search of the literature was conducted to identify studies evaluating interventions for patients with BCI. Databases MEDLINE, CINAHL, PubMed and Scopus were searched from 1990-April 2017. A two-step data extraction process was conducted using pre-defined data fields, including research quality indicators. Each study was appraised using a quality assessment tool, scored for level of evidence, then data collated into categories. Interventions were also assessed using the APEASE criteria then integrated to develop a BCI care bundle.

RESULTS

Eighty-one articles were included in the final analysis. Interventions that improved BCI outcomes were grouped into three categories; respiratory intervention, analgesia and surgical intervention. Respiratory interventions included continuous positive airway pressure and high flow nasal oxygen. Analgesia interventions included regular multi-modal analgesia and paravertebral or epidural analgesia. Surgical fixation was supported for use in moderate to severe rib fractures/BCI. Interventions supported by evidence and that met APEASE criteria were combined into a BCI care bundle with four components: respiratory adjuncts, analgesia, complication prevention, and surgical fixation.

CONCLUSIONS

The key components of a BCI care bundle are respiratory support, analgesia, complication prevention including chest physiotherapy and surgical fixation.

Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials

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.

Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery

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.

A comparison of thoracic or lumbar patient-controlled epidural analgesia methods after thoracic surgery

Background

We aimed to compare patient-controlled thoracic or lumbar epidural analgesia methods after thoracotomy operations.

Methods

One hundred and twenty patients were prospectively randomized to receive either thoracic epidural analgesia (TEA group) or lumbar epidural analgesia (LEA group). In both groups, epidural catheters were administered. Hemodynamic measurements, visual analog scale scores at rest (VAS-R) and after coughing (VAS-C), analgesic consumption, and side effects were compared at 0, 2, 4, 8, 16, and 24 hours postoperatively.

Results

The VAS-R and VAS-C values were lower in the TEA group in comparison to the LEA group at 2, 4, 8, and 16 hours after surgery (for VAS-R, P = 0.001, P = 0.01, P = 0.008, and P = 0.029, respectively; and for VAS-C, P = 0.035, P = 0.023, P = 0.002, and P = 0.037, respectively). Total 24-hour analgesic consumption was different between groups (175 +/- 20 mL versus 185 +/- 31 mL; P = 0.034). The comparison of postoperative complications revealed that the incidence of hypotension (21/57, 36.8% versus 8/63, 12.7%; P = 0.002), bradycardia (9/57, 15.8% versus 2/63, 3.2%; P = 0.017), atelectasis (1/57, 1.8% versus 7/63, 11.1%; P = 0.04), and the need for intensive care unit (ICU) treatment (0/57, 0% versus 5/63, 7.9%; P = 0.03) were lower in the TEA group in comparison to the LEA group.

Conclusions

TEA has beneficial hemostatic effects in comparison to LEA after thoracotomies along with more satisfactory pain relief profile.