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Elmansy S, Abdelkhalek M, Farouk S, Shoukry R, Khames A. Ultrasound -guided erector spinae plane block (ESPB) versus intravenous opioids based analgesia in patients with rib fractures. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2188729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Affiliation(s)
- Soha Elmansy
- Assisstant lecturer at department of anesthia, ICU and pain management, faculty of medicine, Ain shams university
| | - Mohammed Abdelkhalek
- Professor at department of anesthesia, ICU and pain management, faculty of medicine, Ain shams university
| | - Sherif Farouk
- Professor at department of anesthesia, ICU and pain management, faculty of medicine, Ain shams university
| | - Randa Shoukry
- Professor at department of anesthesia, ICU and pain management, faculty of medicine, Ain shams university
| | - Ahmed Khames
- Lecturer at department of Anesthesia, ICU and pain management, faculty of medicine, Ain Shams university
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Elkins MR. Physiotherapy management of rib fractures. J Physiother 2023; 69:211-219. [PMID: 37714770 DOI: 10.1016/j.jphys.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/30/2023] [Indexed: 09/17/2023] Open
Affiliation(s)
- Mark R Elkins
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
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3
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Mercadante S. Alcoholization of Intercostal Nerves for Incident Pain Due to Rib Metastases. J Pain Symptom Manage 2023; 66:e427-e429. [PMID: 37343899 DOI: 10.1016/j.jpainsymman.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Rib metastases may cause incident pain on coughing, deep respiration, or on specific thoracic wall movement. Proper titration of opioid doses relieves the background pain adequately, but does not allow a good pain control for incident pain. METHODS A patient with rib metastases presented incident pain due to minimal chest wall movement, limiting breathing. Alcoholization of intercostal nerves at T6,T7, T8, and T9, at level of ribs angle, RESULTS: Intercostal blocks were highly effective in relieving incident pain due to rib metastases. DISCUSSION A simple and safe procedure may produce effective analgesia preventing incident pain due to rib metastases. Differently from other sites of bone metastases, ribs are easily localized and the neurolytic block results to be effective and safe.
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Affiliation(s)
- Sebastiano Mercadante
- Director of Anesthetics, La Maddalena Cancer Center, (S.M.), Main Regional Center of Pain Relief and Supportive/Palliative Care, Palermo, Italy.
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Sarangarm P, Zimmerman DE, Faine B, Rech MA, Flack T, Gilbert BW, Howington GT, Laub J, Porter B, Slocum GW, Zepeski A, Brown CS. UpdatED: The emergency medicine pharmacotherapy literature of 2022. Am J Emerg Med 2023; 69:136-142. [PMID: 37116295 DOI: 10.1016/j.ajem.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/03/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023] Open
Abstract
The purpose of this article is to summarize pharmacotherapy related emergency medicine (EM) literature indexed in 2022. Articles were selected utilizing a modified Delphi approach. The table of contents from pre-determined journals were reviewed and independently evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by paired authors, with disagreements adjudicated by a third author. Pharmacotherapy-related publications deemed to be GRADE 1A and 1B were reviewed by the group for inclusion in the review. In all, this article summarizes and provides commentary on the potential clinical impact of 13 articles, 4 guidelines, and 3 meta-analyses covering topics including anticoagulant reversal, tenecteplase in acute ischemic stroke, guideline updates for heart failure and aortic aneurysm, magnesium in atrial fibrillation, sedation in mechanically ventilated patients and pain management strategies in the Emergency Department (ED), and tranexamic acid use in epistaxis and GI bleed.
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Affiliation(s)
- Preeyaporn Sarangarm
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM 87106, USA.
| | - David E Zimmerman
- Duquesne University School of Pharmacy, University of Pittsburgh Medical Center-Mercy Hospital, Room 311 Bayer Learning Center, 600 Forbes Avenue, Pittsburgh, PA 15282, USA
| | - Brett Faine
- Department of Emergency Medicine and Pharmacy Practice, University of Iowa, Iowa City, IA 52242, United States of America
| | - Megan A Rech
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood 60153, IL, USA; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, USA
| | - Tara Flack
- Department of Pharmacy, IU Health Methodist Hospital, Indianapolis, IN 46202, USA
| | - Brian W Gilbert
- Department of Pharmacy, Wesley Medical Center, Wichita, KS 67205, USA
| | - Gavin T Howington
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40506, USA; Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY 40536, USA
| | - Jessica Laub
- Department of Pharmacy, New York-Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY 11215, USA
| | - Blake Porter
- Department of Pharmacy, University of Vermont Medical Center, Burlington, VT 05401, USA
| | - Giles W Slocum
- Department of Emergency Medicine and Department of Pharmacy, Rush University Medical Center, Chicago, IL 60612, USA
| | - Anne Zepeski
- Department of Emergency Medicine and Pharmacy Practice, University of Iowa, Iowa City, IA 52242, United States of America
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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5
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Harrington C, Bliss J, Lam L, Partyka C. Serratus Anterior Plane Block for Clinically Suspected Rib Fractures in Prehospital and Retrieval Medicine. PREHOSP EMERG CARE 2022; 28:30-35. [PMID: 36441609 DOI: 10.1080/10903127.2022.2150344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 11/30/2022]
Abstract
Objective: To describe the use of the serratus anterior plane block (SAPB) in the prehospital and retrieval environment including the ability to accurately identify those patients with thoracic trauma and clinically suspected rib fractures who would benefit from this procedure.Methods: This is a retrospective case series of all patients with thoracic trauma and clinically suspected rib fractures who received SAPB by a prehospital and retrieval medical team in New South Wales, Australia, between 2018 and 2021. The primary outcome was to identify the proportion of patients who received appropriate blocks based on the criteria of reporting moderate pain after receiving adequate pre-block analgesia. Secondary outcomes included the proportions of patients with rib fractures identified on thoracic imaging, concomitant time-critical pathology, radiologist identification of fluid adjacent to the serratus anterior muscle, and local anesthetic systemic toxicity.Results: Of the 2004 patients who sustained thoracic trauma, only 13 received a SAPB. Nine (69.2%) met the predetermined definition of appropriate selection. Of the four patients who did not meet this criteria, three reported less than moderate pain and one did not receive adequate pre-block analgesia. There was no significant effect on median scene interval when compared to other thoracic trauma patients who did not receive a SAPB. Ten patients had rib fractures identified on in-patient imaging (chest x-ray or computed tomography (CT)) with a median (IQR) number of ribs fractured of 5 (interquartile range 2-10). Three of these patients had radiological flail segments. Prespecified time-critical pathology was identified in three patients (23.1%) on initial hospital imaging. Five out of eight patients with post-SAPB CT imaging (62.5%) available for radiologist review had fluid identified adjacent to the serratus anterior muscle. None of the 13 patients had local anesthetic systemic toxicity.Conclusion: The SAPB can be safely and successfully performed in the prehospital and retrieval environment, where clinicians can appropriately identify patients with thoracic trauma and clinically suspected rib fractures who would benefit from this technique. Further research is required to identify the ideal patient population to perform the SAPB upon and compare its performance to current analgesic options.
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Affiliation(s)
- Christopher Harrington
- Aeromedical Operations, NSW Ambulance, Bankstown Airport, Australia
- Emergency Department, Prince of Wales Hospital, Randwick, Australia
| | - Jimmy Bliss
- Aeromedical Operations, NSW Ambulance, Bankstown Airport, Australia
- Emergency Department, Liverpool Hospital, Liverpool, Australia
- Sydney Medical School, University of Sydney, Camperdown, Australia
| | - Leon Lam
- Medical Imaging, Liverpool Hospital, Liverpool, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
| | - Christopher Partyka
- Aeromedical Operations, NSW Ambulance, Bankstown Airport, Australia
- Emergency Department, Royal North Shore Hospital, St Leonards, Australia
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Attia H, Ben Saad H, Masmoudi K, Bannour I, Ouaz M, Gardabbou K, Majdoub A. Predictive factors of nebulized morphine failure in North-African patients with chest trauma: a prospective pilot study. Expert Rev Respir Med 2022; 16:1085-1092. [PMID: 36196899 DOI: 10.1080/17476348.2022.2131543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the predictive factors of nebulized morphine (MOR) failure in patients with chest trauma. RESEARCH DESIGN AND METHODS This was an interventional clinical study. Patients admitted with isolated chest trauma with a pain visual analog score > 4 were included. Each patient received 10 mg nebulized MOR. If pain was still > 4 after 10 minutes of nebulization, the latter was repeated every 10 minutes until pain was relieved (i.e. ≤ 4). If pain was > 4 at 30 minutes, nebulized MOR was considered a failure. Patients were divided into two groups: MOR (+) and MOR (-) (good response to and nebulized MOR failure, respectively). RESULTS Seventy-five patients were included. Analysis of the risk factors revealed that road traffic accidents (relative risk (RR): 0.117 [0.031-0.443]; p=0.002), number of fractured ribs > 4 (RR: 0.317 [0.092-0.543]; p=0.006), bilateral injury (RR: 0.114 [0.037-0.349]; p<0.001), flail chest (RR: 0.120 [0.037-0.386]; p<0.001), hemothorax (RR: 0.203 [0.062-0.660]; p=0.008), pulmonary contusion (RR: 0.202 [0.069-0.589]; p=0.003), and pain at admission > 7 (RR: 0.363 [0.147-0.579]; p=0.004) were predictors of nebulized MOR failure. CONCLUSION Our results can help optimize the analgesic management of chest trauma patients by identifying the most eligible patients to benefit from nebulized MOR. CLINICAL TRIAL REGISTRATION : www.clinicaltrials.gov identifier is NCT03580187.
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Affiliation(s)
- Hela Attia
- University of Monastir, Faculty of Medicine of Monastir, Mahdia, Tunisia
| | - Helmi Ben Saad
- University of Sousse, Faculty of Medicine of Sousse, Research Laboratory "Heart Failure, Sousse, Tunisia
| | - Karim Masmoudi
- University of Monastir, Faculty of Medicine of Monastir, Mahdia, Tunisia
| | - Imen Bannour
- University of Monastir, Faculty of Medicine of Monastir, Mahdia, Tunisia
| | - Mouna Ouaz
- University of Monastir, Faculty of Medicine of Monastir, Mahdia, Tunisia
| | - Kais Gardabbou
- University of Monastir, Faculty of Medicine of Monastir, Mahdia, Tunisia
| | - Ali Majdoub
- University of Monastir, Faculty of Medicine of Monastir, Mahdia, Tunisia
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Symanski JS, Ross AB, Davis KW, Brunner MC, Lee KS. US for Traumatic Nerve Injury, Entrapment Neuropathy, and Imaging-guided Perineural Injection. Radiographics 2022; 42:1546-1561. [PMID: 35776677 DOI: 10.1148/rg.210152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
US is commonly performed to help diagnose traumatic peripheral nerve injury and entrapment neuropathy, particularly with superficial nerves, where higher spatial resolution provides an advantage over MRI. Other advantages of US include dynamic evaluation, easy contralateral comparison, fewer implant contraindications, less artifact from ferromagnetic debris, and facile needle guidance for perineural injections. The authors review peripheral nerve US for traumatic peripheral nerve injury with an emphasis on injury grading and entrapment neuropathy and describe best-practice techniques for US-guided perineural injections while highlighting specific techniques and indications. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- John S Symanski
- From the Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792 (J.S.S., A.B.R., K.W.D., M.C.B., K.S.L.); and Department of Radiology, William S. Middleton Veterans Hospital, Madison, Wis (M.C.B.)
| | - Andrew B Ross
- From the Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792 (J.S.S., A.B.R., K.W.D., M.C.B., K.S.L.); and Department of Radiology, William S. Middleton Veterans Hospital, Madison, Wis (M.C.B.)
| | - Kirkland W Davis
- From the Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792 (J.S.S., A.B.R., K.W.D., M.C.B., K.S.L.); and Department of Radiology, William S. Middleton Veterans Hospital, Madison, Wis (M.C.B.)
| | - Michael C Brunner
- From the Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792 (J.S.S., A.B.R., K.W.D., M.C.B., K.S.L.); and Department of Radiology, William S. Middleton Veterans Hospital, Madison, Wis (M.C.B.)
| | - Kenneth S Lee
- From the Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792 (J.S.S., A.B.R., K.W.D., M.C.B., K.S.L.); and Department of Radiology, William S. Middleton Veterans Hospital, Madison, Wis (M.C.B.)
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Palachick BJ, Carver RA, Byars DV, Martyak MT, Collins JN. Erector Spinae Plane Blocks for Traumatic Rib Fractures: A Prospective, Interventional Study. Am Surg 2022; 88:2124-2126. [PMID: 35512648 DOI: 10.1177/00031348221091956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Rib fractures are present in 10% of all trauma patients and 30% of patients with significant chest trauma. Pain from rib fractures results in decreased respiratory effort which can lead to atelectasis and potentially pneumonia and death. Pain control is therefore of utmost importance in preventing the complications of rib fractures by improving respiratory function. Erector spinae plane blocks (ESPB) have been effectively used in elective surgery with subjective and objective improvements in pain. MATERIALS AND METHODS We sought to evaluate subjective pain and objective evaluation of respiratory effort by way of incentive spirometry levels after administration of an ESPB for patients with rib fractures. Our trauma service applied ESPB over 2 years in patients with rib fractures. Ultrasound guidance was used to administer 50cc of a long-acting local anesthetic at the transverse process underneath the erector spinae muscle group. Evaluation of pain scores and incentive spirometry levels were measured prior to and after the ESPB. RESULTS In total, we obtained data from 45 patients. Mean pre-pain scores were 7.93 with post-pain scores of 4.47 (p < 0.001). Mean pre-block incentive spirometry volumes were 1160 cc with post-block IS of 1495cc (p 0.035). There were no associated complications. DISCUSSION ESPBs are safe and significantly reduce pain scores and increased incentive spirometry volumes after administration. They are easy to perform and can be done by the trauma service, including trainees. ESPB has the potential to reduce pulmonary complications of rib fractures, as well as subjectively improving pain experienced by our trauma patients. Based on our results, we recommend this block as an adjunct to multimodal analgesia for patients with rib fractures.
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Affiliation(s)
| | - Ryan A Carver
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Donald V Byars
- Department of Emergency Medicine, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Michael T Martyak
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jay N Collins
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
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Intravenous Lidocaine for the Management of Traumatic Rib Fractures: A Double-Blind Randomized Controlled Trial (INITIATE Program of Research). J Trauma Acute Care Surg 2022; 93:496-502. [PMID: 35137728 DOI: 10.1097/ta.0000000000003562] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Traumatic rib fractures (TRFs) are common with a 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and death. Evidence exists for intravenous (IV) lidocaine's effectiveness and safety in post-operative thoracic and abdominal surgery and we hypothesized it would be effective in patients with TRFs. METHODS We conducted a single-centre, double-blind, randomized control trial comparing IV lidocaine plus usual analgesics to placebo infusion plus usual analgesics for 72-96 hours. Participants were adult trauma patients diagnosed with two or more TRFs requiring hospital admission. The primary outcome was mean pain score at rest and with movement, as measured on the Visual Analog Scale (VAS). Secondary outcomes included patient satisfaction and opioid requirements (standardized total morphine equivalents (TME)). The study was powered to detect a 20% reduction in pain scores, which has been deemed clinically meaningful. RESULTS 36 patients were enrolled and randomized to IV lidocaine or placebo. Comparison of the mean VAS pain scores demonstrated significant pain reduction with movement in the lidocaine group compared to placebo (7.05 ± 1.72 vs 8.22 ± 1.28, p = 0.042). Although pain scores at rest were reduced in the lidocaine group, this difference was not statistically significant (3.37 ± 2.00 vs 3.82 ± 1.97, p = 0.519). Patient satisfaction was higher in the lidocaine group than the placebo group, though this did not reach statistical significance (8.3 (IQR 7.0, 9.6) vs 6.3 (IQR 5.2, 7.1), p = 0.105). TMEs were lower in the lidocaine group than the placebo group, but this difference did not reach statistical significance (167 (IQR 60, 340) vs 290 (IQR 148, 390), p = 0.194). CONCLUSIONS These results demonstrate that lidocaine has a beneficial analgesic effect in patients with TRFs. Future work is needed to evaluate lidocaine's ability to reduce patient important consequences of inadequate analgesia. LEVEL OF EVIDENCE Level 2: RCT with significance and only 1 negative criterion (Missing >20% data).
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Heindel P, Ordoobadi A, El Moheb M, Serventi-Gleeson J, Garvey S, Heyman A, Patel N, Sanchez S, Kaafarani HMA, Herrera-Escobar J, Salim A, Nehra D. Patient-reported outcomes 6 to 12 months after isolated rib fractures: A nontrivial injury pattern. J Trauma Acute Care Surg 2022; 92:277-286. [PMID: 34739001 DOI: 10.1097/ta.0000000000003451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite the ubiquity of rib fractures in patients with blunt chest trauma, long-term outcomes for patients with this injury pattern are not well described. METHODS The Functional Outcomes and Recovery after Trauma Emergencies (FORTE) project has established a multicenter prospective registry with 6- to 12-month follow-up for trauma patients treated at participating centers. We combined the FORTE registry with a detailed retrospective chart review investigating admission variables and injury characteristics. All trauma survivors with complete FORTE data and isolated chest trauma (Abbreviated Injury Scale score of ≤1 in all other regions) with rib fractures were included. Outcomes included chronic pain, limitation in activities of daily living, physical limitations, exercise limitations, return to work, and both inpatient and discharge pain control modalities. Multivariable logistic regression models were built for each outcome using clinically relevant demographic and injury characteristic univariate predictors. RESULTS We identified 279 patients with isolated rib fractures. The median age of the cohort was 68 years (interquartile range, 56-78 years), 59% were male, and 84% were White. Functional and quality of life limitations were common among survivors of isolated rib fractures even 6 to 12 months after injury. Forty-three percent of patients without a preexisting pain disorder reported new daily pain, and new chronic pain was associated with low resilience. Limitations in physical functioning and exercise capacity were reported in 56% and 51% of patients, respectively. Of those working preinjury, 28% had not returned to work. New limitations in activities of daily living were reported in 29% of patients older than 65 years. Older age, higher number of rib fractures, and intensive care unit admission were independently associated with higher odds of receiving regional anesthesia. Receiving a regional nerve block did not have a statistically significant association with any patient-reported outcome measures. CONCLUSION Isolated rib fractures are a nontrivial trauma burden associated with functional impairment and chronic pain even 6 to 12 months after injury. LEVEL OF EVIDENCE Prognostic/epidemiologic, level III.
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Affiliation(s)
- Patrick Heindel
- From the Division of Trauma, Burn and Surgical Critical Care, Department of Surgery (P.H., A.O., M.E.M., A.S.), and Center for Surgery and Public Health (P.H., A.O., M.E.M., J.S.-G., S.G., A.H., N.P., J.H.E., A.S., D.N.), Brigham and Women's Hospital, Harvard Medical School; Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery (S.S.), Boston University School of Medicine, Boston, Massachusetts; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery (H.M.A.K.), Massachusetts General Hospital, Harvard Medical School; and Division of Trauma, Burn and Critical Care Surgery, Department of Surgery (D.N.), University of Washington Medical Center, Seattle, Washington
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11
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Diwan S, Nair A. A retrospective study comparing analgesic efficacy of ultrasound-guided serratus anterior plane block versus intravenous fentanyl infusion in patients with multiple rib fractures. J Anaesthesiol Clin Pharmacol 2021; 37:411-415. [PMID: 34759553 PMCID: PMC8562434 DOI: 10.4103/joacp.joacp_349_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/24/2020] [Accepted: 07/09/2020] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Inadequately managed pain due to multiple rib fractures (MRFs) can lead to atelectasis, pneumonia, prolonged ICU stay thereby leads to significant morbidity, morbidity and cost of treatment. Opioids, non-steroidal anti-inflammatory drugs and regional anaesthesia techniques like thoracic epidural or paravertebral blocks, intercostal nerve blocks are used to manage pain. Serratus anterior plane block (SAPB) is an ultrasound (US) guided interfascial plane block which has been used in managing pain due to MRFs. In this retrospective study, we compared analgesic efficacy and 24 hr fentanyl consumption in patients with MRFs who were managed with continuous SAPB versus patients who were managed with fentanyl infusion alone. Material and Methods After Institutional Ethics Committee approval, we retrospectively collected data of 72 patients (38 in SAPB group and 34 in fentanyl group). Demographic data, VAS scores and 24 hrs fentanyl consumption was analysed in both groups. Results There were statistically significant lower pain scores in patients of SAPB group when compared to that of fentanyl group (p=0.001) and in 24 hrs fentanyl consumption in patients who received continuous SAPB versus that in fentanyl group(p=0.001). No complications were observed in patients who received US guided SAPB. Conclusion US guided SAPB is an opioid sparing, effective interfascial plane block which is safe and should be considered early in all patients who sustain MRFs. Continuous SAPB by placing a catheter can provide pain relief for longer duration, facilitate early mobilization, physiotherapy and early ICU discharge.
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Affiliation(s)
- Sandeep Diwan
- Department of Anaesthesiology, Sancheti Hospital, Pune, Maharashtra, India
| | - Abhijit Nair
- Department of Anaesthesiology, Ibra Hospital, North Sharqiya Governorate, Ibra-414, Sultanate of Oman
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12
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Liao SW, Su FW, Ting CK, Yang CF, Yang CW, Tsou MY, Chiang HK. Intercostal Nerve Block Using an Innovative Intraneedle Ultrasound Transducer: A Proof-of-Concept study. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1881-1892. [PMID: 33836903 DOI: 10.1016/j.ultrasmedbio.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/03/2021] [Accepted: 03/01/2021] [Indexed: 06/12/2023]
Abstract
Intercostal nerve block is a widely used and effective approach to providing regional anesthesia in the thoracic region for pain relief. However, during ultrasound-guided intercostal nerve block, inaccurate identification of the anatomic structures or suboptimal positioning of the needle tip may result in complications and blockade failure. In this study, we designed an intraneedle ultrasound (INUS) system and validated its efficacy in identifying anatomic structures relevant to thoracic region anesthesia. The 20-MHz INUS transducer comprised a single lead magnesium niobate-lead titanate crystal, and gain was set to 20 dB. It fit into a regular 18G needle and emitted radiofrequency-mode ultrasound signals at 1 mm from the needle tip. One hundred intercostal punctures were performed in 10 piglets. Intercostal spaces were identified by surface ultrasound or palpation and located by inserting and advancing the INUS transducer needle until the appropriate anatomy was identified. Blockade success was defined by ideal saline and dye spreading and confirmed by dissection. The pleura had a distinctive ultrasound signal, and successful detection of the intercostal muscles, endothoracic fascia and double-layered parietal and visceral pleura was achieved in all 100 puncture attempts. INUS allows real-time identification of intercostal structures and facilitates successful intercostal nerve blocks.
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Affiliation(s)
- Shu-Wei Liao
- Department of Anesthesiology, Chi-Mei Medical Center, Tainan, Taiwan, ROC
| | - Fu-Wei Su
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Institute of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chien-Kun Ting
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ching-Fang Yang
- Institute of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chia-Wei Yang
- Institute of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Mei-Yung Tsou
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Huihua K Chiang
- Institute of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan, ROC.
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13
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Deng G, Gofeld M, Reid JN, Welk B, Agur AM, Loh E. A Retrospective Cohort Study of Healthcare Utilization Associated with Paravertebral Blocks for Chronic Pain Management in Ontario. CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR 2021; 5:130-138. [PMID: 34263095 PMCID: PMC8253135 DOI: 10.1080/24740527.2021.1929883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Injections, particularly paravertebral blocks (PVBs), are frequently performed procedures in Ontario, Canada, for the management of chronic pain, despite limited evidence and risk of complications. Aim: This study examines usage patterns of PVBs to evaluate their effects on healthcare utilization and opioid prescribing. Methods: A retrospective cohort study in Ontario using administrative data. Ontario residents receiving their initial PVBs between July 1, 2013 and March 31, 2018 were included. Changes in use of other interventions, physician visits, and opioids were compared to the 12-month periods before and after index PVBs. Data use was authorized under section 45 of Ontario's Personal Health Information Protection Act. Results: 47,723 patients received their initial PVBs in the study period. The rate of index PVBs increased from 1.61 per 10,000 population (2013) to 2.26 per 10,000 (2018). Initial PVBs were performed most commonly by family physicians (N = 25,042), followed by anesthesiologists (N = 14,195). 23,386 patients (49%) received 1 to 9 repeat PVBs in the 12 months after index PVB; 12,474 patients (26.15%) received 10 or more. Use of other nonimage guided interventional pain procedures per patient (mean±SD) increased from 2.19 ± 9.35 to 31.68 ± 52.26 in the year before and after index PVB. Relevant physician visits per patient (mean±SD) also increased from 2.92 ± 3.61 to 9.64 ± 11.77. Mean opioid dosing did not change significantly between the year before and the year after index PVB. Conclusion: PVBs are associated with increases in healthcare utilization and no change in opioid use patterns.
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Affiliation(s)
| | | | | | - Blayne Welk
- ICES, Ontario, Canada.,Department of Surgery, Western University, London, Ontario, Canada
| | - Anne Mr Agur
- Division of Anatomy, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Eldon Loh
- Department of Physical Medicine and Rehabilitation, Western University, London, Ontario, Canada.,Parkwood Institute Research, Lawson Health Research Institute, London, Ontario, Canada
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Risk of Pneumonia in Pediatric Patients Following Minor Chest Trauma: A Population-Based Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094690. [PMID: 33924886 PMCID: PMC8124241 DOI: 10.3390/ijerph18094690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/14/2021] [Accepted: 04/26/2021] [Indexed: 11/17/2022]
Abstract
This study investigated the association between minor chest trauma and the risk of pneumonia among pediatric patients in a Taiwanese health care setting. For this retrospective population-based cohort study, the Longitudinal Health Insurance Database was used to analyze the data of patients with a minor chest injury between 2010 and 2012. Data were analyzed through a multivariate analysis with a multiple Cox regression model. Patients were divided into a chest trauma group (n = 6592) and a non-chest trauma group (n = 882,623). An increased risk of pneumonia was observed in the chest trauma group (hazard ratio = 1.23; 95% confidence interval = 1.02–1.49) compared to the non-chest trauma group. In conclusion, this population-based cohort study demonstrated that pediatric patients with minor chest trauma are at an increased risk of pneumonia. The short-term adverse effects of pneumonia could be severe when a patient suffers from mild chest trauma.
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Çiftçi H, Gezginaslan Ö. The Effectiveness of Intercostal Nerve Block on Return to Work, Quality of Life, and Hand Grip Strength in Patients with Isolated Rib Fractures: a Single-Blind, Randomized Controlled Study. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02784-4] [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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16
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The Comparison of Analgesics and Kinesiological Taping in Rib Fractures. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02856-5] [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] Open
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17
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The Effects of Add-On Self-Care Therapy on Epidural Catheter Analgesia and Pain in Patients after Surgical Stabilization of Multiple Rib Fractures. Pain Manag Nurs 2021; 22:764-768. [PMID: 33674241 DOI: 10.1016/j.pmn.2021.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/29/2020] [Accepted: 01/24/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Epidural (EPI) catheter analgesia is frequently prescribed as a regional analgesic technique to patients with multiple rib fractures (MRF) following surgical stabilization of rib fractures (SSRF). AIMS We aimed to study the effect of add-on self-care therapy on recovery and quality of life (QoL) in patients on EPI analgesia after surgical stabilization of rib fractures (SSRF). DESIGN/SETTINGS/PARTICIPANTS/SUBJECTS A total of 267 eligible patients with MRF who received EPI catheter analgesia after SSRF were recruited, and assigned to one of two groups in a random fashion: intervention group received education on self-care therapy, while the control group did not. METHODS Pain scores, incentive spirometry (IS) volumes, oxygen saturation (SpO2), respiratory rate, hospital length of stay (LoS) and QoL were evaluated. RESULTS Compared with control group, the intervention group showed significantly improved pain scores, IS volume, respiratory rate, and SpO2. Hospital LoS was shorter for the intervention group than the control group. Overall QoL scores in the intervention group were also significantly better than control patients. CONCLUSIONS Education on self-care therapy significantly benefited pain management, recovery, and QoL for patients with MRF who received EPI catheter analgesia after SSRF operation.
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18
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Analgesic efficacy of the serratus anterior plane block in rib fractures pain: A randomized controlled trial. Am J Emerg Med 2020; 41:16-20. [PMID: 33383266 DOI: 10.1016/j.ajem.2020.12.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/13/2020] [Accepted: 12/13/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Serratus anterior plane block (SAPB) was evaluated that in patients with the complaint of rib fracture pain in terms of total analgesic consumption and pain scores. METHOD Sixty patients with rib fracture and NRS (Numeric Rating Scala) pain scores equal or greater than four were included in randomized controlled study. Patients were randomized to perform SAPB or control group. Primary outcome was total tramadol consumption in 24 h. Secondary outcomes were NRS scores (after Patient Controlled Analgesia (PCA) application 30 min, first, second, 4 th, 6 th, 12 th, 24 th hour), peripheral oxygen saturation (first and 24 th hour after PCA application), chronic pain. and complications. RESULTS The total tramadol consumption significantly lower in group S (p = 0.02). NRS scores after 30 min, 1 h, 2 h, 4 h, 6 h, 12 h, and 24 h were significantly lower in group S than in group C (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.002, p = 0.026). The total number of patients who reported of chronic pain at rest and during effort was significantly lower in group SAPB than in group C (p = 0.006). Nine patients in group C were reported of pain, four of whom had pain at rest and five had pain during effort. One patient in group S was reported of pain during effort. CONCLUSION This study demonstrated that SAPB, as part of multimodal analgesia in pain management due to rib fractures, is safe and effective in reducing acute pain.
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Gerloni R, Artusi N, Sisto UG, Tollot S, Copetti R. A serious fit of cough: A 66-year-old patient with myasthenia gravis presenting with spontaneous intercostal lung herniation after coughing. Case report and pathophysiological discussion. EMERGENCY CARE JOURNAL 2020. [DOI: 10.4081/ecj.2020.8911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We present a case of a 66-year-old man with history of myasthenia gravis, severe obesity and osteopenia self-presented to our Emergency Department (ED) with severe pain in his left hemithorax, occurred after an episode of cough three days before. No history of trauma was reported. The patient underwent a chest-XR showing uncomplicated spontaneous fractures of the 5th and 6th left ribs. He was therefore discharged with appropriate analgesic treatment. Five days later, the patient came back to our ED for a wide left abdominal hematoma, though hemodynamically stable and eupneic. A CT-scan with contrast showed a rare and unexpected spontaneous left intercostal lung herniation complicated with a diffuse subcutaneous emphysema, pneumothorax, loculated bilateral pleural effusion and abdominal hematoma. The patient was admitted, treated conservatively and safely discharged after two weeks. We also provide a pathophysiological discussion of the case and a literature review.
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20
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Zhang L, Liu W, You H, Chen Z, Xu L, He H. Assessing the analgesic efficacy of oral epigallocatechin-3-gallate on epidural catheter analgesia in patients after surgical stabilisation of multiple rib fractures: a prospective double-blind, placebo-controlled clinical trial. PHARMACEUTICAL BIOLOGY 2020; 58:741-744. [PMID: 32749173 PMCID: PMC7470119 DOI: 10.1080/13880209.2020.1797123] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/25/2020] [Accepted: 06/15/2020] [Indexed: 05/24/2023]
Abstract
CONTEXT Thoracic trauma results in multiple rib fractures (MRF), and surgical stabilisation of rib fractures (SSRF) can relieve fracture pain. Epigallocatechin-3-gallate (EGCG) is reported to exhibit beneficial effects in bone-related metabolic and differentiation processes. OBJECTIVE To study the clinical effect of EGCG on regional analgesia for pain relief in MRF patients after SSRF. MATERIALS AND METHODS Ninety-seven MRF patients (61 males, 36 females) who were on epidural catheter analgesia after SSRF were recruited. They were randomly divided into: oral EGCG 100 mg (oral grade) twice daily for 10 days and placebo groups. Pain scores, incentive spirometry (IS) volumes, respiratory rate and oxygen saturation (SpO2) were assessed day 10 after SSRF. RESULTS Comparing results from the placebo and EGCG group, in the 10-day intervention course, oral EGCG reduced pain score (8 at base line vs. 4 at end of intervention in EGCG group, p < 0.05; 4 in EGCG group vs. 6 in placebo group at end of intervention, p < 0.05), improved IS volume (713 at base line vs. 1072 at end of intervention in EGCG group, p < 0.05; 1072 in EGCG group vs. 953 in placebo group at end of intervention, p < 0.05) and respiratory rate (24 at base line vs. 15 at end of intervention in EGCG group, p < 0.05; 15 in EGCG group vs. 19 in placebo group at end of intervention, p < 0.05). However, no further enhancing effect on SpO2 was observed in the EGCG group (0.98 in EGCG group vs. 0.98 in placebo group at end of intervention, p > 0.05). DISCUSSION AND CONCLUSIONS Although the study is limited by a relatively small sample size and lack of serum factor analysis, the key results and the study design, for the first time, nevertheless pave the way for trials with larger number of patients to understand the effect of EGCG in MRF patients that are undergoing SSRF.
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Affiliation(s)
- Lihong Zhang
- Department of Anesthesiology, Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Weifeng Liu
- Department of Anesthesiology, Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Haiping You
- Department of Anesthesiology, Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Zhiyuan Chen
- Department of Anesthesiology, Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Liming Xu
- Department of Anesthesiology, Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Hefan He
- Department of Anesthesiology, Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
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21
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Hsu JM, Clark PT, Connell LE, Welfare M. Efficacy of high-flow nasal prong therapy in trauma patients with rib fractures and high-risk features for respiratory deterioration: a randomized controlled trial. Trauma Surg Acute Care Open 2020; 5:e000460. [PMID: 32885050 PMCID: PMC7451286 DOI: 10.1136/tsaco-2020-000460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/05/2020] [Accepted: 06/11/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Patients with rib fractures require analgesia, oxygen supplementation and physiotherapy. This combination has been shown to reduce morbidity and mortality due to rib fractures. There has been movement towards the use of high-flow nasal prong (HFNP) oxygen. However there are no studies demonstrating the effectiveness of HFNP in this population. The aim of this study was to compare HFNP to venturi mask (VM) in rib fracture patients. METHODS Randomized controlled trial. Patient population included patients with rib fractures and high-risk features (three or more rib fractures, flail segment, bilateral rib fractures, smoker or chronic obstructive pulmonary disease). Exclusion criteria included initial mechanical ventilation and contraindications to HFNP. Patients were randomized to HFNP or VM. Primary outcome was deterioration requiring mechanical invasive/non-invasive ventilation, or unplanned admission to intensive care unit. Secondary outcomes included mortality, length of stay, high dependency length of stay, comfort levels, breathing exertion levels (as measured by Borg Scale), oxygen saturation, respiratory rate, heart rate, chest X-ray and arterial blood gas parameters. RESULTS 220 patients (average age 60 years and average of four rib fractures each) were randomized to HFNP (n=113) and VM (n=107). There was no statistically significant difference in the primary outcome comparing HFNP and VM (6.2% vs. 6.5%, p=1.0). There were also no statistically significant differences in the secondary outcomes except for PaCO2 (43.6 vs. 45.5, p=0.039). CONCLUSION HFNP oxygen supplementation does not appear to be more effective than VM oxygen supplementation in patients with rib fractures.
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Affiliation(s)
- Jeremy Ming Hsu
- Trauma Service, Westmead Hospital, Westmead, New South Wales, Australia
| | - Peter Telford Clark
- Westmead Hospital Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Matthew Welfare
- Trauma Service, Westmead Hospital, Westmead, New South Wales, Australia
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22
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Johnson M, Strait L, Ata A, Bartscherer A, Miller C, Chang A, Stain SC, Tafen M. Do Lidocaine Patches Reduce Opioid Use in Acute Rib Fractures? Am Surg 2020; 86:1153-1158. [PMID: 32812770 DOI: 10.1177/0003134820945224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pain control is an important aspect of rib fracture management. With a rise in multimodal care approaches, we hypothesized that transdermal lidocaine patches reduce opioid utilization in hospitalized patients with acute rib fractures not requiring continuous opioid infusion. METHODS We performed a retrospective analysis of adult trauma patients with acute rib fractures admitted to the Trauma Service from January 2011 to October 2018. We compared patients who received transdermal lidocaine patches to those who did not and evaluated cumulative opioid consumption, expressed in morphine milligram equivalents (MMEs). Secondary outcomes included the rate of pulmonary complications and length of hospital stay. RESULTS Of the 21 190 trauma admissions, 3927 (18.5%) had rib fractures. Overall, 1555 patients who received continuous opioid infusion were excluded. Of the remaining 2372 patients, 725 (30.6%) patients received lidocaine patches. The mean total MME of patients who received lidocaine patches was 55.7 MME (30.7 MME on multivariate analysis) and was lower than that of patients who did not receive lidocaine patches (P ≤ .01). There was no difference in hospital length of stay (no lidocaine patches vs received lidocaine patches: 6.2 days vs 6.5 days, P = .34) or pulmonary complications (1.7% vs 2.8%, P = .08). DISCUSSION In admitted trauma patients with acute rib fractures not requiring continuous intravenous opiates, lidocaine patch use was associated with a significant decrease in opiate utilization during the patients' hospital course.
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Affiliation(s)
- Matthew Johnson
- Department of Surgery, Division of Trauma Surgery, Albany Medical Center, NY, USA
| | - Lauren Strait
- Department of Surgery, Division of Trauma Surgery, Albany Medical Center, NY, USA
| | - Ashar Ata
- Department of Surgery, Division of Trauma Surgery, Albany Medical Center, NY, USA
| | - Ashley Bartscherer
- Department of Surgery, Division of Trauma Surgery, Albany Medical Center, NY, USA
| | - Claire Miller
- Department of Surgery, Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Andrew Chang
- Department of Emergency Medicine, Albany Medical Center, Albany, NY, USA
| | - Steven C Stain
- Department of Surgery, Division of Trauma Surgery, Albany Medical Center, NY, USA
| | - Marcel Tafen
- Department of Surgery, Division of Trauma Surgery, Albany Medical Center, NY, USA
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Antill AC, Frye SW, McMillen JC, Haynes JC, Ford BR, Bollig RW, Daley BJ. Treatment With Oral Versus Intravenous Acetaminophen in Elderly Trauma Patients With Rib Fractures: A Prospective Randomized Trial. Am Surg 2020; 86:926-932. [PMID: 32749863 DOI: 10.1177/0003134820940268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Rib fractures are common injuries among traumatically injured patients, and elderly patients with rib fractures are at increased risk for adverse events and death. The purpose of this study was to determine if oral Per os (PO) acetaminophen is as effective as intravenous (IV) acetaminophen in treating the pain associated with rib fractures. METHODS We performed a single-center, randomized, placebo-controlled, double-blinded study. Trauma patients who were ≥65 years old and had ≥1 rib fracture were included in this study. Patients were randomized into IV acetaminophen and oral placebo (n = 63) or IV placebo and oral solution acetaminophen (n = 75) groups. The primary outcome was a mean reduction in pain score at 24 hours, and secondary outcomes included opioid use, intensive care unit (ICU) length of stay (LOS), hospital LOS, hospital mortality, the difference in incentive spirometry, and development of pneumonia. RESULTS Among the 138 patients included, there was no statistically significant difference between the 2 study groups in a mean reduction in pain score at 24 hours after injury (PO: 3.24, IV: 2.49; P = .230). Opioid pain medication use was equivalent between groups (P = .212), and there was no significant difference in hospital mortality rate between groups (P = .827). There was no statistically significant difference in ICU LOS, hospital LOS, or development of pneumonia. DISCUSSION In elderly trauma patients (age ≥65 years) with 1 or more rib fractures, PO acetaminophen is equivalent to IV acetaminophen for pain control, with no difference in morbidity or mortality. Oral acetaminophen should be preferentially used over IV acetaminophen when treating the elderly trauma patient with rib fractures.
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Affiliation(s)
- Andrew C Antill
- 21823 Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Sarah W Frye
- Department of Pharmacy, Spartanburg Medical Center, SC, USA
| | - James C McMillen
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA
| | - James C Haynes
- Department of Surgery, WellStar North Fulton Hospital, Roswell, GA, USA
| | - Benjamin R Ford
- Department of Surgery, Roper Saint Francis Healthcare, Charleston, SC, USA
| | - Reagan W Bollig
- 21823 Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Brian J Daley
- 21823 Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA
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The Sequential Clinical Assessment of Respiratory Function (SCARF) score: A dynamic pulmonary physiologic score that predicts adverse outcomes in critically ill rib fracture patients. J Trauma Acute Care Surg 2020; 87:1260-1268. [PMID: 31425473 DOI: 10.1097/ta.0000000000002480] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rib fracture scoring systems are limited by a lack of serial pulmonary physiologic variables. We created the Sequential Clinical Assessment of Respiratory Function (SCARF) score and hypothesized that admission, maximum, and rising scores predict adverse outcomes among critically ill rib fracture patients. METHODS Prospective cohort study of rib fracture patients admitted to the surgical intensive care unit (ICU) at a Level I trauma center from August 2017 to June 2018. The SCARF score was developed a priori and validated using the cohort. One point was assigned for: <50% predicted, respiratory rate >20, numeric pain score ≥5, and inadequate cough. Demographics, injury patterns, analgesics, and adverse pulmonary outcomes were abstracted. Performance characteristics of the score were assessed using the receiver operator curve area under the curve. RESULTS Three hundred forty scores were available from 100 patients. Median admission and maximum SCARF score was 2 (range 0-4). Likelihood of pneumonia (p = 0.04), high oxygen requirement (p < 0.01), and prolonged ICU length of stay (p < 0.01) were significantly associated with admission and maximum scores. The receiver operator curve area under the curve for the maximum SCARF score for these outcomes were 0.86, 0.76, and 0.79, respectively. In 10 patients, the SCARF score worsened from admission to day 2; these patients demonstrated increased likelihood of pneumonia (p = 0.04) and prolonged ICU length of stay (p = 0.07). Patients who developed complications maintained a SCARF score one point higher throughout ICU stay compared with patients who did not (p = 0.04). The SCARF score was significantly associated with both narcotic (p = 0.03) and locoregional anesthesia (p = 0.03) usage. CONCLUSION Admission, maximum, daily, and rising scores were associated with utilization of pain control therapies and development of adverse outcomes. The SCARF score may be used to guide therapies for critically ill rib fracture patients, with a proposed threshold greater than 2. LEVEL OF EVIDENCE Prognostic study, level II.
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Abstract
BACKGROUND There remains a lack of knowledge about readmission characteristics after sustaining rib fractures. We aimed to determine rates, characteristics, and predictive/protective factors associated with unexpected reevaluation and readmission after rib cage injury. METHODS A retrospective review was performed based on trauma patients evaluated at an urban Level I trauma center from January 2014 to December 2016. Adult patients sustaining blunt trauma with more than one rib fracture or a sternomanubrial fracture were defined as having moderate to severe rib cage injury. Exclusion criteria included penetrating injury, death during initial hospitalization, and only one rib fracture. Reevaluation was defined as presenting at a hospital within 90 days of discharge urgently or emergently. Demographics, injury characteristics, comorbidities, complications, imaging, and readmission data were collected. Univariate and multivariate analysis was performed with a significance of p less than 0.05. RESULTS During the study period, 11,667 patients underwent trauma evaluation, of which 1,717 patients were found to have a moderate to severe rib cage injury. Within 90 days, 397 (23.1%) of patients underwent reevaluation, while 177 (10.3%) required readmission. One hundred forty-two (8.3%) patients were reevaluated specifically for chest-related complaints, and 55 (3.2%) required readmission. On univariate analysis, Injury Severity Score greater than 15, hospital length of stay longer than 7 days, intensive care unit (ICU) length of stay longer than 3 days, a worsened chest x-ray at discharge, a psychiatric comorbidity, a smoking comorbidity, deep vein thrombosis, unplanned readmission to the ICU, and unplanned intubation were higher in the overall reevaluation cohort. On multivariate analysis, age of 15 years to 35 years, Risk Assessment Profile score greater than 8, hypertension, psychiatric comorbidity, current smoker, and unplanned return to the ICU on index admission were predictive of reevaluation of overall reevaluation. CONCLUSION Moderate to severe rib cage injury is associated with high rates of reevaluation and readmission. Younger patients who smoke and required a return to the ICU are at greater risk for readmission. LEVEL OF EVIDENCE Level IV, Prognostic and Epidemiologic.
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Ketamine infusion for pain control in adult patients with multiple rib fractures: Results of a randomized control trial. J Trauma Acute Care Surg 2020; 86:181-188. [PMID: 30376537 DOI: 10.1097/ta.0000000000002103] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rib fractures occur in up to 40% of trauma patients and are associated with increased mortality. Opiate-based pain regimens remain the cornerstone of rib fracture management; however, concerns around opioids have fostered interest in alternative analgesics. Ketamine is currently being used in lieu of opioids, but little evidence exists supporting its use within the trauma population. METHODS A prospective, randomized, double-blind placebo-controlled trial of adult patients with three or more rib fractures admitted to a Level I trauma center was conducted. Exclusion criteria included age older than 64 years, Glasgow Coma Scale score less than 13, and chronic opiate use. The experimental arm received low-dose ketamine (LDK) at 2.5 μg·kg·min while the placebo cohort received an equivalent rate of 0.9% normal saline. All infusions were continued for 48 hours. The primary outcome was reduction in numeric pain score (NPS) during the first 24 hours. Secondary outcomes studied included oral morphine equivalent (OME) utilization, length of stay, epidural rates, pulmonary complications, and adverse events. RESULTS Forty-five (49%) of 91 patients were randomized to the experimental arm. Both groups were similar in makeup. Overall, 74.7% were male, had a median age of 49 years, and an Injury Severity Score (ISS) of 14. Low-dose ketamine was not associated with a significant reduction in 24-hour NPS or OME totals. Subgroup analysis of 45 severely injured patients (ISS, >15) demonstrated that LDK was associated with a significant reduction in OME utilization during the first 24 hours (35.7 vs. 68, p = 0.03), 24 hours to 48 hours (64.2 vs. 96, p = 0.03), and overall (152.1 vs. 198, p = 0.048). No difference in other secondary outcomes or adverse events was noted. CONCLUSION Low-dose ketamine failed to decrease NPS or OME within the overall cohort, but a decrease in OME was observed among patients with an ISS greater than 15. Confirmatory studies are necessary to determine if LDK is a useful adjunct among severely injured patients. LEVEL OF EVIDENCE Therapeutic study, level II.
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Ketamine infusion for pain control in elderly patients with multiple rib fractures: Results of a randomized controlled trial. J Trauma Acute Care Surg 2020; 87:1181-1188. [PMID: 31425468 DOI: 10.1097/ta.0000000000002479] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Rib fractures are associated with increased mortality, particularly in the elderly. While opiate-based pain regimens remain the cornerstone of rib fracture management, issues related to opioids have driven research into alternative analgesics. Adjunctive ketamine use in lieu of opioids continues to increase but little evidence exists to support its efficacy or safety within the elderly trauma population. METHODS A prospective, randomized, double-blind placebo-controlled trial of elderly patients (age, ≥65 years) with three or more rib fractures admitted to a Level I trauma center was conducted. Exclusion criteria included Glasgow Coma Scale score less than 14, and chronic opiate use. Groups were randomized to either low-dose ketamine (LDK) at 2 μg·kg·min or an equivalent rate of 0.9% normal saline. The primary outcome was reduction in numeric pain scores (NPS). Secondary outcomes included oral morphine equivalent (OME) utilization, epidural rates, pulmonary complications, and adverse events. RESULTS Thirty (50.8%) of 59 were randomized to the experimental arm. Groups were similar in makeup. Low-dose ketamine failed to reduce 24-hour NPS or OME totals. Subgroup analysis of 24 patients with Injury Severity Score greater than 15 demonstrated that LDK was associated with a reduction in OME utilization the first 24-hours (25.6 mg vs. 42.6 mg, p = 0.04) but at no other time points. No difference in other secondary outcomes or adverse events was noted. CONCLUSION Low-dose ketamine failed to affect NPS or OME within the overall cohort, but a decrease in OME was observed in those with an Injury Severity Score greater than 15. Additional studies are necessary to confirm whether LDK benefits severely injured elderly patients. LEVEL OF EVIDENCE Therapeutic, level I.
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Akça AH, Şaşmaz Mİ, Kaplan Ş. Kinesiotaping for isolated rib fractures in emergency department. Am J Emerg Med 2020; 38:638-640. [PMID: 31937442 DOI: 10.1016/j.ajem.2019.11.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/25/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Rib fractures, which are among the most common injuries in blunt thoracic trauma, are usually encountered in Emergency Departments. Kinesiotape (KT) is a drug-free elastic therapeutic tape used for treating various musculoskeletal problems such as injury, dysfunction and pain. We aimed to investigate whether kinesotaping should be used safely and effectively in rib fractures in emergency setting. MATERIALS AND METHODS This was a prospective, randomized controlled study conducted in an Emergency Department of a University Hospital. Patients diagnosed with isolated rib fractures were included in the study. Pain severity of patients assessed with 0-10 cm visual analog scale (VAS), then patients assigned into 2 treatment groups. One of them received treatment with flurbiprofen 200 mg/day and the other group received kinesiotaping in addition to the same oral therapy. On the 4th day of the procedure, both groups were assessed with VAS in the followup visit. RESULTS Total of 82 patients presented with rib fractures, 52 of them were excluded. Remaining 30 constituted the study group and randomly allocated to kinesiotaping (n = 16) or control group (n = 14). In both groups, pain intensity on the 4th day was significantly reduced when compared with baseline (p for both<0.01). Additionally, considering the reducing the pain intensity on 4th day, kinesiotaping was significantly superior than the control group (p < 0.01). CONCLUSION This study investigated the use of kinesiotaping in emergency departments. When compared to NSAID therapy alone, combined kinesiotaping and NSAID therapy appears to be more effective in terms of pain reduction in rib fractures.
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Affiliation(s)
- Ali Haydar Akça
- Yüzüncü Yıl University, Faculty of Medicine, Department of Emergency Medicine, Turkey
| | - Muhammed İkbal Şaşmaz
- Manisa Celal Bayar University, Faculty of Medicine, Department of Emergency Medicine, Turkey.
| | - Şeyhmus Kaplan
- Yüzüncü Yıl University, Faculty of Medicine, Department of Sports Medicine, Turkey
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Factors that influence the quality of pain management in patients with skin traction. Int J Orthop Trauma Nurs 2020; 36:100713. [DOI: 10.1016/j.ijotn.2019.100713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/30/2019] [Accepted: 08/18/2019] [Indexed: 11/20/2022]
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Zhang JP, Sun L, Li WQ, Wang YY, Li XZ, Liu Y. Surgical treatment ofpatients with severe non-flail chest rib fractures. World J Clin Cases 2019; 7:3718-3727. [PMID: 31799296 PMCID: PMC6887616 DOI: 10.12998/wjcc.v7.i22.3718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/08/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Many patients have inadequate long-term analgesia, respiratory distress, and hypoxemia due to a long-standing substantial smoking history or the presence of primary pulmonary diseases; analgesic treatment is not valid in these patients. Even if the imaging findings of rib fractures are relatively mild, rib fractures may cause severe position limitation, respiratory distress, and hypoxemia.
AIM To investigate the curative effect of surgical treatment for patients with severe non-flail chest rib fractures.
METHODS A total of 78 patients from our hospital with severe noncontinuous thoracic rib fractures from September 2016 to September 2018 were enrolled in our study. Thirty-nine patients underwent surgical treatment, and 39 underwent conservative treatment. The surgical treatment group received surgery performed with titanium plates, and the screws were inserted with open reduction and internal fixation. The conservative treatment group received analgesia and symptomatic treatment. The pain scores at 72 h, 1 wk, 2 wk, 4 wk, 6 wk, 3 mo, and 6 mo were compared, and the SF-36 quality of life scores were compared atthe 3rd and 6th months.
RESULTS Pain relief in the surgical group was significantly better than that in the conservative group at each time point (72 h, 1 wk, 2 wk, 4 wk, 6 wk, 3 mo, and 6 mo after surgery, P < 0.001). ( The SF-36 scores were significantly higher in the surgical group than in the conservative group at 1 mo and 6 mo (P < 0.05).
CONCLUSION Patients with severe non-flail chest rib fractures have a better quality of life following surgical treatment than following conservative treatment, and surgical treatment is also useful for relieving pain. We should pay more attention to the physiological functions and clinical manifestations of patients with severe rib fractures. In patients with non-flail chest rib fractures, surgical treatment is feasible and effective.
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Affiliation(s)
- Jian-Peng Zhang
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Lin Sun
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Wei-Qiang Li
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Yan-Yu Wang
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Xin-Zhen Li
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
| | - Yang Liu
- Department of Thoracic Surgery, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China
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Lynch N, Salottolo K, Foster K, Orlando A, Koola C, Portillo V, Tanner A, Mains CW, Bar-Or D. Comparative effectiveness analysis of two regional analgesia techniques for the pain management of isolated multiple rib fractures. J Pain Res 2019; 12:1701-1708. [PMID: 31213882 PMCID: PMC6538881 DOI: 10.2147/jpr.s198350] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 03/23/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Catheter-based regional analgesia has been proposed as an alternative to systemic analgesia for patients with multiple rib fractures (MRF). This study sought to compare the efficacy of regional techniques for decreasing pain and improving clinical outcomes. Study design: This was a multi-institutional, retrospective cohort study of adult (≥18 years) patients admitted to four nonacademic trauma centers over two years (from 07/1/2014 to 06/30/2016). Study inclusion was MRF (≥3 fractures) with no other severe injuries. Two primary regional analgesia techniques were utilized and compared: continuous intercostal nerve blocks (CINB) and epidural (EPI) analgesia. The primary outcome, average pain scores on treatment, was examined using a repeated measures, linear regression mixed model. Secondary outcomes included hospital LOS, ICU LOS, ICU admission and hospital readmission, pulmonary complications, and incentive spirometry volumes during treatment, and were examined with univariate statistics. Results: There were 339 patients with isolated MRF; 85 (25%) required regional analgesia (CINB, n=41; EPI, n=44) and the remaining 75% received systemic analgesia only (IV, n=195; PO, n=59). There were demographic and clinical differences between regional analgesia and systemic analgesia groups; on the contrary, there were no demographic or clinical differences between the CINB and EPI groups. Adjusted pain scores were similar for the EPI and CINB groups (4.0 vs 4.4, p=0.49). Secondary outcomes were worse in the EPI group compared to the CINB group: less improvement in incentive spirometry volume (p=0.004), longer ICU LOS (p=0.03), longer hospital LOS (p<0.001), and more ICU admission (p<0.001). Conclusion: In patients requiring regional analgesia, pain management was equivalent with CINB and EPI, but CINB was associated with significantly better clinical outcomes. CINB might offer an efficient alternative for pain control in patients with MRF.
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Affiliation(s)
- Neal Lynch
- Trauma Services Department, Penrose-St. Francis Health Services, Colorado Springs, CO, USA
| | - Kristin Salottolo
- Trauma Services Department, Penrose-St. Francis Health Services, Colorado Springs, CO, USA.,Swedish Medical Center, Trauma Research Department, Englewood, CO, USA.,Medical City Plano, Trauma Research Department, Plano, TX, USA.,St. Anthony Hospital, Trauma Research Department, Lakewood, CO, USA
| | - Krislyn Foster
- Swedish Medical Center, Trauma Research Department, Englewood, CO, USA
| | - Alessandro Orlando
- Trauma Services Department, Penrose-St. Francis Health Services, Colorado Springs, CO, USA.,Swedish Medical Center, Trauma Research Department, Englewood, CO, USA.,Medical City Plano, Trauma Research Department, Plano, TX, USA.,St. Anthony Hospital, Trauma Research Department, Lakewood, CO, USA
| | - Catherine Koola
- Trauma Services Department, Penrose-St. Francis Health Services, Colorado Springs, CO, USA.,Swedish Medical Center, Trauma Research Department, Englewood, CO, USA.,Medical City Plano, Trauma Research Department, Plano, TX, USA.,St. Anthony Hospital, Trauma Research Department, Lakewood, CO, USA
| | - Victor Portillo
- Medical City Plano, Trauma Research Department, Plano, TX, USA
| | - Allen Tanner
- Trauma Services Department, Penrose-St. Francis Health Services, Colorado Springs, CO, USA
| | - Charles W Mains
- St. Anthony Hospital, Trauma Research Department, Lakewood, CO, USA.,Centura Health, Trauma Services Department, Englewood, CO, USA
| | - David Bar-Or
- Trauma Services Department, Penrose-St. Francis Health Services, Colorado Springs, CO, USA.,Swedish Medical Center, Trauma Research Department, Englewood, CO, USA.,Medical City Plano, Trauma Research Department, Plano, TX, USA.,St. Anthony Hospital, Trauma Research Department, Lakewood, CO, USA
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Epidural Analgesia for Severe Chest Trauma: An Analysis of Current Practice on the Efficacy and Safety. Crit Care Res Pract 2019; 2019:4837591. [PMID: 31016043 PMCID: PMC6444241 DOI: 10.1155/2019/4837591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/15/2019] [Accepted: 02/19/2019] [Indexed: 11/17/2022] Open
Abstract
Background Adequate pain control is essential in the treatment of patients with traumatic rib fractures. Although epidural analgesia is recommended in international guidelines, the use remains debatable and is not undisputed. The aim of this study was to describe the efficacy and safety of epidural analgesia in patients with multiple traumatic rib fractures. Methods A retrospective cohort study was performed. Patients with ≥3 rib fractures following blunt chest trauma who received epidural analgesia between January 2015 and January 2018 were included. The main outcome parameters were the success rate of epidural analgesia and the incidence of medication-related side effects and catheter-related complications. Results A total of 76 patients were included. Epidural analgesia was successful in a total of 45 patients (59%), including 22 patients without and in 23 patients with an additional analgesic intervention. In 14 patients (18%), epidural analgesia was terminated early without intervention due to insufficient sensory blockade (n=4), medication-related side effects (n=4), and catheter-related complications (n=6). In 17 patients (22%), the epidural catheter was removed after one or multiple additional interventions due to insufficient pain control. Minor epidural-related complications or side effects were encountered in 36 patients (47%). One patient had a major complication (opioid intoxication). Conclusion Epidural analgesia was successful in 59% of patients; however, 30% needed additional analgesic interventions. As about half of the patients had epidural-related complications, it remains debatable whether epidural analgesia is a sufficient treatment modality in patients with multiple rib fractures.
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Puzio T, Mangat S, Strassle P, Sredzienski E, Reid T, Brownstein M. Lidocaine Infusion as an Adjunct to Narcotics in Trauma Patients with Rib Fractures—A Pilot Study. Am Surg 2019. [DOI: 10.1177/000313481908500401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Thaddeus Puzio
- University of North Carolina Chapel Hill, North Carolina
| | - Sabrina Mangat
- University of North Carolina Chapel Hill, North Carolina
| | - Paula Strassle
- University of North Carolina Chapel Hill, North Carolina
| | | | - Trista Reid
- University of North Carolina Chapel Hill, North Carolina
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Weinberg B, Roos R, van Aswegen H. Effectiveness of non-pharmacological interventions for pain and physical function in adults with rib fractures: a systematic review protocol. ACTA ACUST UNITED AC 2018; 16:1599-1605. [PMID: 30113543 DOI: 10.11124/jbisrir-2017-003600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVES The review question is: what are the effects of non-pharmacological therapeutic interventions on pain and physical function in adults with rib fractures?The objectives of this systematic review are to determine.
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Affiliation(s)
- Beverley Weinberg
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ronel Roos
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,The Wits-JBI Centre for Evidenced-Based Practice: a Joanna Briggs Institute Centre of Excellence
| | - Heleen van Aswegen
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Guo C, Lei M, Wang Y, Hua L, Xue S, Yu D, Zhang C, Wang D. Oral Administration of Probiotic Lactobacillus Casei Shirota Decreases Pneumonia and Increases Pulmonary Functions after Single Rib Fracture: A Randomized Double-Blind, Placebo-Controlled Clinical Trial. J Food Sci 2018; 83:2222-2226. [PMID: 30020533 DOI: 10.1111/1750-3841.14220] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/04/2018] [Accepted: 05/18/2018] [Indexed: 12/13/2022]
Abstract
Considerate proportion of elderly patients with a rib fracture is susceptible to pulmonary complications, especially pneumonia. We aimed to assess the effect of oral administration of the probiotic Lactobacillus casei Shirota (LcS) on pneumonia and pulmonary functions among elderly patients with single rib fracture. The current study including 204 eligible elderly patients with a single rib fracture was conducted. Patients were randomly assigned to receive oral administration of skimmed milk containing either a commercial probiotic LcS or placebo daily for 1 mo after the fracture, followed by pneumonia assessments, pulmonary function testing including forced expiratory volume (FEV), negative inspiratory pressure (NIP), and forced vital capacity (FVC), as well as evaluation of potential adverse effects including myocardial infarction, acute kidney injury, nonunion of fractured bone, or stroke. After 1 mo consumption, patients in the LcS group exhibited decreased pneumonia and increased recovery of pulmonary functions, in terms of FEV, FVC, and NIP, compared to the placebo group. No difference was observed in incidence of adverse events between the 2 groups. In patients with a single rib fracture, oral administration of the probiotic LcS was associated with a lower incidence of pneumonia and increased pulmonary functions without causing severe adverse effects. PRACTICAL APPLICATION To conclude, after 1-mo LcS consumption, in patients with a single rib fracture, oral administration of the probiotic LcS was associated with a lower incidence of pneumonia and increased pulmonary functions without causing severe adverse effects.
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Affiliation(s)
- Chunhua Guo
- Dept. of Orthopedics, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Min Lei
- Dept. of Nutrition and Diet, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Yong Wang
- Dept. of Orthopedics, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Limei Hua
- Dept. of Nutrition, Bethune Int. Heping Hospital, No. 398, Zhong Shan West Road, Shijiazhuang, 050082, Hebei Province, China
| | - Sujuan Xue
- Dept. of Nutrition and Diet, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Dan Yu
- Dept. of Nutrition and Diet, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Chunhua Zhang
- Dept. of Emergency Medicine, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
| | - Dawei Wang
- Dept. of Oral and Maxillofacial Surgery, the Third Hospital of Hebei Medical Univ., No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei Province, China
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Jensen CD, Stark JT, Jacobson LL, Powers JM, Joseph MF, Kinsella-Shaw JM, Denegar CR. Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures. PAIN MEDICINE 2018; 18:1787-1794. [PMID: 27550958 DOI: 10.1093/pm/pnw199] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Each year, more than 150,000 patients with rib fractures are admitted to US trauma centers; as many as 10% die. Effective pain control is critical to survival. One way to manage pain is thoracic epidural analgesia. If this treatment reduces mortality, more frequent use may be indicated. Methods We analyzed the patient registry of a level II trauma center. All patients admitted with one or more rib fractures (N = 1,347) were considered. Patients who were not candidates for epidural analgesia (N = 382) were eliminated. Mortality was assessed with binary logistic regressions. Results Across the total population, mortality was 6.7%; incidence of pneumonia was 11.1%; mechanical ventilation was required in 23.8% of patients, for an average duration of 10.0 days; average stay in the hospital was 7.7 nights; and 49.7% of patients were admitted to the ICU for an average of 7.2 nights. Epidural analgesia was administered to 18.4% of patients. After matching samples for candidacy, patients who received epidurals were 3.7 years older, fractured 2.6 more ribs, had higher injury severity scores, and were more likely to present with bilateral fractures, flail segments, pulmonary contusions, hemothoraces, and pneumothoraces. Despite greater injury severity, mortality among these patients was lower (0.5%) than those who received alternative care (1.9%). Controlling for age, injury severity, and use of mechanical ventilation, epidural analgesia predicted a 97% reduction in mortality. Conclusion Thoracic epidural analgesia associates with reduced mortality in rib fracture patients. Better care of this population is likely to be facilitated by more frequent reliance on this treatment.
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Affiliation(s)
- Courtney D Jensen
- Department of Health, Exercise, and Sport Sciences, University of the Pacific, Stockton, California
| | | | | | | | - Michael F Joseph
- Department of Kinesiology, University of Connecticut, Storrs, Connecticut, USA
| | | | - Craig R Denegar
- Department of Kinesiology, University of Connecticut, Storrs, Connecticut, USA
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Lee Y, Lee SH, Kim C, Choi HJ. Comparison of the effectiveness in pain reduction and pulmonary function between a rib splint constructed in the ER and a manufactured rib splint. Medicine (Baltimore) 2018; 97:e10779. [PMID: 29794759 PMCID: PMC6393019 DOI: 10.1097/md.0000000000010779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In the treatment of patients with rib fractures (RFs), pain reduction is the most important consideration. Various studies have examined the effectiveness of treatments administered to RF patients, such as lidocaine patches, IV drugs, nerve blockers, and surgery. In this study, we evaluated the difference in the effectiveness in pain reduction between 2 groups of RF patients: 1 group who received a rib splint constructed in the ER (ER splint) and another group who received a Chrisofix Chest Orthosis (CCO) manufactured rib splint. METHODS A pilot study for a prospective randomized clinical trial was conducted to compare subjects using the CCO (Group A) with those using the ER splint (Group B) before and after the intervention. The primary outcome was difference in the level of pain based on the visual analogue scale (VAS) and the pulmonary function (PF) variables between before and after intervention in each group during forceful and resting respiration. RESULTS A total of 24 subjects were enrolled in this study. The VAS results showed that the intervention was significantly effective in each group (before vs after: Group A resting: 8.50 ± 1.05 vs 4.17 ± 1.33, P < .001; Group A forceful: 9.83 ± 0.41 vs 7.17 ± 0.75, P < .001; Group B resting: 8.83 ± 1.60 vs 4.50 ± 1.38, P < .001; and Group B forceful: 9.67 ± 0.82 vs 7.33 ± 1.51, P = .003). The PF variables showed that the intervention was significantly effective in each group (before vs after: Group A, FVC: 2.74 ± 0.92 vs 3.35 ± 0.99, P < .001; FEV1: 2.16 ± 0.74 vs 2.57 ± 0.78, P = .001; PEF: 235.30 ± 43.06 vs 319.00 ± 51.58, P = .004; and Group B, FVC: 2.02 ± 0.49 vs 2.72 ± 0.62, P < .001; FEV1: 1.27 ± 0.25 vs 1.91 ± 0.37, P < .001; PEF: 216.67 ± 67.49 vs 300.33 ± 87.79, P = .003). CONCLUSION Applying either the CCO or the ER splint to RF patients effectively reduced pain, and no significant differences in pain level were observed between these 2 techniques.
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Affiliation(s)
- Yoonje Lee
- Department of Emergency Medicine, Seoul Hospital, Hanyang University, Gyeonggi-do
| | - Sang-Hyun Lee
- Department of Emergency Medicine, Hangang Sacred Heart Hospital, Hallym University, Gangwon-do
| | - Changsun Kim
- Department of Emergency Medicine, Guri Hospital, Hanyang University, Gyeonggi-do, Korea
| | - Hyuk Joong Choi
- Department of Emergency Medicine, Guri Hospital, Hanyang University, Gyeonggi-do, Korea
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Agamohammdi D, Montazer M, Hoseini M, Haghdoost M, Farzin H. A Comparison of Continuous Thoracic Epidural Analgesia with Bupivacaine Versus Bupivacaine and Dexmedetomidine for Pain Control in Patients with Multiple Rib Fractures. Anesth Pain Med 2018; 8:e60805. [PMID: 30009148 PMCID: PMC6035480 DOI: 10.5812/aapm.60805] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/03/2018] [Accepted: 04/10/2018] [Indexed: 11/16/2022] Open
Abstract
Background The control of pain in traumatic patients with chest injury leading to rib fracture is one of the primary goals in traumatic patients. The efficacy of the thoracic epidural approach in comparison with other approaches for relieving post-thoracotomy pain is unknown. The goal of the present study was to compare thoracic epidural analgesia with bupivacaine alone and in combination with dexmedetomidine in patients with multiple rib fractures. Methods 64 traumatic patients with multiple rib fractures were selected and randomly assigned to two similar groups. For pain relief, a thoracic epidural catheter was inserted to infuse bupivacaine alone or the combination of bupivacaine and dexmedetomidine. Then, we recorded and analyzed pain scores and ABG changes. Results Based on the results, the two approaches could result in proper analgesia, but analgesia with the combination of bupivacaine and dexmedetomidine was significantly improved compared to bupivacaine alone (P < 0.05). In addition, ABG of patients significantly changed when the combination of bupivacaine and dexmedetomidine was used within 2 to 4 days (P < 0.05). Conclusions The results of the present study showed that epidural infusion of a combination of bupivacaine and dexmedetomidine could provide better control of rib fracture pain in traumatic patients, and is a proper alternative for bupivacaine alone.
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Affiliation(s)
| | - Majid Montazer
- Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding author: Majid Montazer, Assistant Professor, Thoracic Surgery, Tabriz University of Medical Sciences, Tabriz, Iran. Tel: +98-9143134672, E-mail:
| | | | | | - Haleh Farzin
- Tabriz University of Medical Sciences, Tabriz, Iran
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Zhang L, McMahon CJ, Shah S, Wu JS, Eisenberg RL, Kung JW. Clinical and Radiologic Predictive Factors of Rib Fractures in Outpatients With Chest Pain. Curr Probl Diagn Radiol 2018; 47:94-97. [DOI: 10.1067/j.cpradiol.2017.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/10/2017] [Accepted: 05/16/2017] [Indexed: 11/22/2022]
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Farahmand S, Hamrah H, Arbab M, Sedaghat M, Basir Ghafouri H, Bagheri-Hariri S. Pain management of acute limb trauma patients with intravenous lidocaine in emergency department. Am J Emerg Med 2017; 36:1231-1235. [PMID: 29254669 DOI: 10.1016/j.ajem.2017.12.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 12/11/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION This study was designed to assess the possible superiority of intravenous lidocaine to morphine for pain management. METHODS This was a randomized double blind controlled superiority trial, carried on in the emergency department (ED). Traumatic patients older than 18-year-old with the complaint of acute pain greater than 4 on a numeric rating scale (NRS) from 0 to 10 on their extremities were eligible. One group received IV lidocaine (1.5 mg/kg), and the other received IV morphine (0.1mg/kg). Pain scores and adverse effects were assessed at 15, 30, 45 and 60 minutes and patients' satisfaction was evaluated two hours later. A minimum pain score reduction of 1.3 from baseline was considered clinically significant. RESULTS Fifty patients with the mean age of 31.28±8.7 were enrolled (78% male). The demographic characteristics and pain scores of the two groups was similar. The on-arrival mean pain scores in two groups were, lidocaine: 7.9±1.4 and morphine: 8.0±1.4 (p=0.57) and after 1 hour were, lidocaine: 2.28±1.2 and morphine: 3.2±1.7. Although the pain score decreased significantly in both group (p=0.027), there were not any clinically and statistically significant difference between the two groups (p=0.77). Patients' satisfaction with pain management in both groups were almost similar (p=0.49). CONCLUSION The reduction in pain score using IV lidocaine is not superior to IV morphine in adult ED patients with traumatic limb pain.
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Affiliation(s)
- Shervin Farahmand
- Emergency Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Hadid Hamrah
- Tehran University of Medical Sciences, Tehran, Iran
| | - Mona Arbab
- General Surgery Department, Brigham and Women's Hospital, Boston, MA, USA
| | - Mojtaba Sedaghat
- Community Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Basir Ghafouri
- Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran
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Abstract
PURPOSE Flail chest (FC) injuries represent a significant burden on trauma services because of its high morbidity and mortality. Current gold standard conservative management strategies for FC, are now being challenged by renewed interest in surgical rib fixation. This retrospective epidemiological study sets out to evaluate FC patients, and quantify the natural history of this injury by studying the injury patterns, epidemiology and mortality of patients sustaining FC injuries admitted to a major trauma centre (MTC). METHODS A retrospective cohort analysis has been conducted at an MTC with full trauma service. All patients (age > 16 years) sustaining FC were included. Patient demographics, injury characteristics and inpatient stay information were extracted. RESULTS Two hundred and ninety-three patients were identified, with a mean injury severity score (ISS) of 28.9 (range 9-75), average age of 56.1 years (range of 16-100), and a male predominance (78%). Road traffic accidents accounted for 45% (n = 132) of injuries, whilst 44% were fall or jump from height (n = 129). Associated lung contusion was present in 133 patients (45%) while 76% of patients were found to have 5 or more ribs involved in the flail segment (n = 223) with 96% (n = 281) having a unilateral FC. Inpatient treatment was required 19.9 days (range 0-150 days) with 59% of patients (n = 173) requiring intensive care unit (ICU) level care for 8.4 days (range 1-63) with 61.8% requiring mechanical ventilation (n = 107) for 10.5 days (range 1-54), and 7.8% underwent rib fixation with rib plates (n = 23). The mortality rate was found to be 14% (n = 42). A non-significant trend towards improved outcomes in the conservative group was found when compared with the fixation group; ventilation days (6.94 vs 10.06, p = 0.18) intensive treatment unit (ITU) length of stay (LOS) (12.56 vs 15.53, p = 0.28) and hospital LOS (32.62 vs 35.24, p = 0.69). CONCLUSION This study has successfully described the natural history of flail chest injuries, and has found a nonsignificant trend towards better outcomes with conservative management. With the cohort and management challenges now defined, work on outcome improvement can be targeted. In addition the comparability of results to other studies makes collaboration with other MTCs a realistic proposal.
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Ekpe EE, Eyo C. Effect of analgesia on the changes in respiratory parameters in blunt chest injury with multiple rib fractures. Ann Afr Med 2017; 16:120-126. [PMID: 28671152 PMCID: PMC5579895 DOI: 10.4103/aam.aam_73_16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Blunt chest injury with multiple rib fractures can result in such complications as pneumonia, atelectasis, bronchiectasis, empyema thoracis, acute respiratory distress syndrome, and prolonged Intensive Care Unit and hospital stay, with its concomitant mortality. These may be prevented or reduced by good analgesic therapy which is the subject of this study. METHODS This was a prospective study of effects of analgesia on changes in pulmonary functions of patients with traumatic multiple rib fractures resulting from blunt chest injury. RESULTS There were 64 adult patients who were studied with multiple rib fractures caused by blunt chest trauma. Of these patients, 54 (84.4%) were male and 10 (15.6%) were female. Motorcycle (popularly known as "okada") and tricycle (popularly known as keke napep) accidents significantly accounted for the majority of the multiple rib fractures, that is, in 50 (78.1%) of the patients. Before analgesic administration, no patient had a normal respiratory rate, but at 1 h following the administration of analgesic, 21 (32.8%) of patients recorded normal respiratory rates and there was a significant reduction in the number (10.9% vs. 39.1%) of patients with respiratory rates> 30 breaths/min. Before commencement of analgesic, no patient recorded up to 99% of oxygen saturation (SpO2) as measured by pulse oximeter, while 43.8% recorded SpO2of 96%. This improved after 1 h of administration of analgesics to SpO2of 100% in 18.8% of patients and 99% in 31.3% of patients and none recording SpO2of < 97% (P = 0.006). Before analgesia, no patient was able to achieve peak expiratory flow rate (PEFR) value> 100% of predicted while only 9 (14.1%) patients were able to achieve a PEFR value in the range of 91%-100% of predicted value. One hour after analgesia, a total of 6 (9.4%) patients were able to achieve PEFR values> 100% predicted, while 35 (54.7%) patients achieved PEFR values in the range of 91%-100% predicted. CONCLUSION Adequate analgesia is capable of reversing the negative effects of chest pain of traumatic multiple rib fractures on pulmonary function parameters through improvement in respiratory mechanics.
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Affiliation(s)
- Eyo Effiong Ekpe
- Department of Surgery, Cardiothoracic Surgery Unit, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
| | - Catherine Eyo
- Department of Anaesthesia, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
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Malekpour M, Hashmi A, Dove J, Torres D, Wild J. Analgesic Choice in Management of Rib Fractures. Anesth Analg 2017; 124:1906-1911. [DOI: 10.1213/ane.0000000000002113] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Wooster M, Reed D, Tanious A, Illig K. Postoperative Pain Management following Thoracic Outlet Decompression. Ann Vasc Surg 2017; 44:241-244. [PMID: 28479443 DOI: 10.1016/j.avsg.2017.03.175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/04/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Thoracic outlet decompression (TOD) is associated with significant postoperative pain often leading to hospital length of stay out of proportion to the risk profile of the operation. We seek to describe the improvement in hospital length of stay and patient pain control with an improved multiagent pain management regimen. METHODS We retrospectively reviewed the hospital length of stay, medication regimen/usage, operative details, and operative indications for all patients undergoing TOD from January 2012 through June 2015. During early experience, single-agent narcotic therapy was the mainstay of postoperatively pain control. Since 2014, we have adopted a regimen consisting of narcotic patient controlled analgesia, oral narcotics, and scheduled ibuprofen and valium, which is transitioned to oral narcotics/valium upon discharge. Operative approach (supraclavicular, infraclavicular, transaxial, or paraclavicular) was determined by patient anatomy and indication for procedure (neurogenic/arterial thoracic outlet syndrome or arteriovenous access dysfunction). RESULTS Seventy-four patients were treated with TOD over the study period: 36 (49.3%) for neurogenic thoracic outlet syndrome, 23 (31.5%) for venous thoracic outlet syndrome, and 15 (19.2%) for arteriovenous access dysfunction. Prior to 2014, the mean length of stay was 4 days with a median pain score of 6. Since 2014, the mean length of stay was 2.6 (P = 0.04) with a median pain score of 4 (P = 0.005). There was no statistically significant difference in the indication for operation or operative approach between the two periods. CONCLUSIONS Since adoption of a multiagent pain management regimen to include scheduled NSAIDs and benzodiazepines, we have reduced the mean pain score experienced by our patients as well as the hospital length of stay.
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Affiliation(s)
- Mathew Wooster
- Division of Vascular and Cardiothoracic Surgery, College of Medicine, University of South Florida, Tampa, FL.
| | - Dana Reed
- Division of Vascular and Cardiothoracic Surgery, College of Medicine, University of South Florida, Tampa, FL
| | - Adam Tanious
- Division of Vascular and Cardiothoracic Surgery, College of Medicine, University of South Florida, Tampa, FL
| | - Karl Illig
- Division of Vascular and Cardiothoracic Surgery, College of Medicine, University of South Florida, Tampa, FL
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Systemic administration of mesenchymal stem cells combined with parathyroid hormone therapy synergistically regenerates multiple rib fractures. Stem Cell Res Ther 2017; 8:51. [PMID: 28279202 PMCID: PMC5345153 DOI: 10.1186/s13287-017-0502-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/18/2017] [Accepted: 02/09/2017] [Indexed: 01/08/2023] Open
Abstract
Background A devastating condition that leads to trauma-related morbidity, multiple rib fractures, remain a serious unmet clinical need. Systemic administration of mesenchymal stem cells (MSCs) has been shown to regenerate various tissues. We hypothesized that parathyroid hormone (PTH) therapy would enhance MSC homing and differentiation, ultimately leading to bone formation that would bridge rib fractures. Methods The combination of human MSCs (hMSCs) and a clinically relevant PTH dose was studied using immunosuppressed rats. Segmental defects were created in animals’ fifth and sixth ribs. The rats were divided into four groups: a negative control group, in which animals received vehicle alone; the PTH-only group, in which animals received daily subcutaneous injections of 4 μg/kg teriparatide, a pharmaceutical derivative of PTH; the hMSC-only group, in which each animal received five injections of 2 × 106 hMSCs; and the hMSC + PTH group, in which animals received both treatments. Longitudinal in vivo monitoring of bone formation was performed biweekly using micro-computed tomography (μCT), followed by histological analysis. Results Fluorescently-dyed hMSCs were counted using confocal microscopy imaging of histological samples harvested 8 weeks after surgery. PTH significantly augmented the number of hMSCs that homed to the fracture site. Immunofluorescence of osteogenic markers, osteocalcin and bone sialoprotein, showed that PTH induced cell differentiation in both exogenously administered cells and resident cells. μCT scans revealed a significant increase in bone volume only in the hMSC + PTH group, beginning by the 4th week after surgery. Eight weeks after surgery, 35% of ribs in the hMSC + PTH group had complete bone bridging, whereas there was complete bridging in only 6.25% of ribs (one rib) in the PTH-only group and in none of the ribs in the other groups. Based on the μCT scans, biomechanical analysis using the micro-finite element method demonstrated that the healed ribs were stiffer than intact ribs in torsion, compression, and bending simulations, as expected when examining bone callus composed of woven bone. Conclusions Administration of both hMSCs and PTH worked synergistically in rib fracture healing, suggesting this approach may pave the way to treat multiple rib fractures as well as additional fractures in various anatomical sites. Electronic supplementary material The online version of this article (doi:10.1186/s13287-017-0502-9) contains supplementary material, which is available to authorized users.
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Jensen CD, Stark JT, Jacobson LE, Powers JM, Leslie KL, Kinsella-Shaw JM, Joseph MF, Denegar CR. Implications of Thoracic Epidural Analgesia on Hospital Charges in Rib Fracture Patients. PAIN MEDICINE 2017; 19:160-168. [DOI: 10.1093/pm/pnw353] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Hunasikatti M. In Reference to "When Personality Is the Problem: Managing Patients With Difficult Personalities on the Acute Care Unit". J Hosp Med 2017; 12:201. [PMID: 28272601 DOI: 10.12788/jhm.2708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Mahadevappa Hunasikatti
- Spotsylvania Regional Medical Center, Frederiksberg, Virginia, and Food and Drug Administration, Respiratory Branch, Silver Spring, MD, USA
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Chien CY, Chen YH, Han ST, Blaney GN, Huang TS, Chen KF. The number of displaced rib fractures is more predictive for complications in chest trauma patients. Scand J Trauma Resusc Emerg Med 2017; 25:19. [PMID: 28241883 PMCID: PMC5330007 DOI: 10.1186/s13049-017-0368-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 02/21/2017] [Indexed: 01/18/2023] Open
Abstract
Background Traumatic rib fractures can cause chest complications that need further treatment and hospitalization. We hypothesized that an increase in the number of displaced rib fractures will be accompanied by an increase in chest complications. Methods We retrospectively reviewed the trauma registry between January 2013 and May 2015 in a teaching hospital in northeastern Taiwan. Patients admitted with chest trauma and rib fractures without concomitant severe brain, splenic, pelvic or liver injuries were included. The demographic data, such as gender, age, the index of coexistence disease, alcohol consumption, trauma mechanisms were analyzed as potential predictors of pulmonary complications. Pulmonary complications were defined as pneumothorax, hemothorax, flail chest, pulmonary contusion, and pneumonia. Results In the 29 months of the study period, a total of 3151 trauma patients were admitted to our hospital. Among them, 174 patients were enrolled for final analysis. The most common trauma mechanism was road traffic accidents (58.6%), mainly motorbike accidents (n = 70, 40.2%). Three or more displaced rib fractures had higher specificity for predicting complications, compared to three or more total rib fractures (95.5% vs 59.1%). Adjusting the severity of chest trauma using TTSS and Ribscore by multivariable logistic regression analysis, we found that three or more rib fractures or any displaced rib fracture was the most significant predictor for developing pulmonary complication (aOR: 5.49 95% CI: 1.82–16.55). Furthermore, there were 18/57 (31.6%) patients with fewer than three ribs fractures developed pulmonary complications. In these 18 patients, only five patients had delayed onset complications and four of them had at least one displaced rib fracture. Discussion In this retrospective cohort study, we found that the number of displaced or total rib fractures, bilateral rib fractures, and rib fractures in more than two areas were associated with the more chest complications. Furthermore, three or more rib fracture or any displacement were found to be the most sensitive risk factor for chest complications, independent of other risk factors or severity index. Conclusion The number of displaced rib fractures could be a strong predictor for developing pulmonary complications. For patients with fewer than three rib fractures without rib displacement and initial lung or other organ injuries, outpatient management could be safe and efficient. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0368-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chih-Ying Chien
- Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yu-Hsien Chen
- Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shih-Tsung Han
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Gerald N Blaney
- Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ting-Shuo Huang
- Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kuan-Fu Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan. .,Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan. .,Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan.
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Carrie C, Stecken L, Scotto M, Durand M, Masson F, Revel P, Biais M. Forced vital capacity assessment for risk stratification of blunt chest trauma patients in emergency settings: A preliminary study. Anaesth Crit Care Pain Med 2017; 37:67-71. [PMID: 28109938 DOI: 10.1016/j.accpm.2016.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/29/2016] [Accepted: 12/14/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to assess the performance of Forced Vital Capacity (FVC) for prediction of secondary respiratory complications in blunt chest trauma patients. METHODS During a 15-month period, all consecutive blunt chest trauma patients admitted in our emergency intensive care unit with more than 3 rib fractures were eligible, unless they required mechanical ventilation in the prehospital or emergency settings. FVC was measured at admission and at emergency discharge after therapeutic interventions. The main outcome was the occurrence of secondary respiratory complications defined by hospital-acquired pulmonary infection, secondary admission in the intensive care unit or mechanical ventilation for respiratory failure or death. The performance of FVC for prediction of secondary respiratory complications was assessed by receiver operating characteristic (ROC) curve and multivariate analysis after logistic regression. RESULTS Sixty-two consecutive patients were included and 13 (21%) presented secondary respiratory complications. Only FVC measured at emergency discharge - not FCV at admission - was significantly lower in patients who developed secondary respiratory complications (44±15 vs. 61±20%, P=0.002). The area under the ROC curves for FCV in predicting secondary pulmonary complications was 0.79 [95% CI: 0.66-0.88], P=0.0001. An FVC at discharge≤50% was independently associated with the occurrence of secondary complications with an OR at 7.9 [1.9-42.1], P=0.004. CONCLUSION The non-improvement of FVC≤50% at emergency discharge is associated with secondary respiratory complications and should prevent the under-triage of patients with no sign of respiratory failure at admission.
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Affiliation(s)
- Cédric Carrie
- Anesthesiology and Critical Care Department I, CHU Bordeaux, 33000 Bordeaux, France.
| | - Laurent Stecken
- Emergency Department, CHU de Bordeaux, 33000 Bordeaux, France
| | - Marion Scotto
- Anesthesiology and Critical Care Department I, CHU Bordeaux, 33000 Bordeaux, France
| | - Marion Durand
- Emergency Department, CHU de Bordeaux, 33000 Bordeaux, France
| | - Françoise Masson
- Anesthesiology and Critical Care Department I, CHU Bordeaux, 33000 Bordeaux, France
| | - Philippe Revel
- Emergency Department, CHU de Bordeaux, 33000 Bordeaux, France
| | - Matthieu Biais
- Anesthesiology and Critical Care Department III, CHU Bordeaux, 33000 Bordeaux, France; University Bordeaux Segalen, 33000 Bordeaux, France
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