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

[Specialised Intensive Care Treatment Concepts for Severe Chest Trauma]

This review covers key elements of the critical care management of patients with thoracic trauma. Contrast-enhanced chest computertomography remains the diagnostic modality of choice, as it is more sensitive than conventional chest imaging. Regarding risk stratification, special caution is required in older patients with thoracic trauma given their high risk for posttraumatic complications. In the case of respiratory insufficiency, an attempt of non-invasive ventilation techniques is justified in most patients due to potential treatment benefits. Achieving sufficient pain control is a fundamental goal of critical care management. In this regard, erector-spinae-block and paravertebral block present potentially advantageous alternatives to thoracic epidural anaesthesia. In stable patients, the placement of small-calibre chest tubes may be a beneficial approach compared with large-bore tubes. If surgical stabilization of rib fractures is indicated, it should be done as early as possible.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Very long-term effects of conservatively treated blunt thoracic trauma: A retrospective analysis

INTRODUCTION

Despite the high incidence of blunt thoracic trauma and frequently performed conservative treatment, studies on very long-term consequences for these patients remain sparse in current literature. In this study, we identify prevalence of long-term morbidity such as chronic chest pain, shortness of breath, and analyze the effect on overall quality of life and health-related quality of life.

METHODS

Questionnaires were send to patients admitted for blunt thoracic trauma at our institution and who were conservatively treated between 1997 and 2019. We evaluated the presences of currently existing chest pain, persistence of shortness of breath after their trauma, the perceived overall quality of life, and health-related quality of life. Furthermore, we analyzed the effect of pain and shortness of breath on overall quality of life and health-related quality of life.

RESULTS

The study population consisted of 185 trauma patients with blunt thoracic trauma who were admitted between 1997 and 2019, with a median long term follow up of 11 years. 60 percent still experienced chronic pain all these years after trauma, with 40,7 percent reporting mild pain, 12,1 percent reporting moderate pain, and with 7,7 percent showing severe pain. 18 percent still experienced shortness of breath during exercise. Both pain and shortness of breath showed no improvement in this period. Pain and shortness of breath due to thoracic trauma were associated with a lower overall quality of life and health-related quality of life.

CONCLUSION

Chronic pain and shortness of breath may be relatively common long after blunt thoracic trauma, and are of influence on quality of life and health-related quality of life in patients with conservatively treated blunt thoracic trauma.

A novel minimally invasive fixation method for flail chest management in a Canine model: an animal research

BACKGROUND

Multiple rib fractures can lead to flail chest with up to 35% mortality rate due to severe pulmonary complications. Current treatments of flail chest remain controversial. Studies have shown that surgical treatments can improve outcomes and reduce mortality, comparing to non-operative treatments. Current surgical fixation methods focus on stabilization of ribs on the outward facing side, and they require division of intercostal muscles. Damages to surrounding nerves and vessels may lead to chronic pain. This study tests a novel interior fixation method that minimizes neurovascular injuries.

METHODS

Twelve healthy canines were divided in two surgical operation groups for exterior and interior fixation using titanium metal plates. Osteotomy with oblique fractures was prepared under general anesthesia. Exterior fixation was performed in open surgery. Interior fixation was minimally invasive using custom made tools including a flexible shaft extension screwdriver, solid plate stand, guiding wire loop and metal plates with threaded holes.

RESULTS

Respiratory and cardiovascular functions (RR, PO2, PCO2, SpO2, and HR) together with body temperature were measured before anesthesia and within 48 h after surgery. The difference in measurements was not statistically significant between the two groups before surgery with P values greater than 0.05. However, the interior group canines had better RR and PO2 values starting from the 24th hour, and better PCO2, SpO2, and HR values starting from the 48th hour. It took longer operation time to complete the minimally invasive interior fixation surgery (P value less than 0.001), but the total blood loss was less than the exterior fixation group (P value less than 0.001). Results also showed that interior group canines suffered less pain, and they had quicker recovery in gastrointestinal and physical mobility.

CONCLUSIONS

The investigative interior fixation method was safe and effective in rib stabilization on a canine rib fracture model, comparing to the exterior fixation method. The interior fixation was minimally invasive, with less damages to tissues and nerves surrounding the ribs, leading to better postoperative outcomes.

Evaluation of Acute Outcomes and Factors Influencing the Care of Chest Trauma in a District General Hospital in the United Kingdom

Background The rate of chest trauma admissions under the Queen Hospital Burton Orthopedic team has been steadily increasing, surpassing other hospital trusts. Patients are managed locally by the Orthopedic department, unlike in major trauma centres. Understanding the management outcomes and patient factors in this setting is crucial for enhancing patient safety. Methodology A retrospective analysis of 139 patients with chest trauma referred to the QHB Orthopedic team from October 2017 to May 2021 was conducted using the Meditech-V6 electronic medical records system (Meditech, Westwood, US). This study aims to evaluate the outcomes of patients admitted with chest trauma and improve current practices. The objectives include assessing patient factors influencing outcomes, initiating discussions with a major trauma centre, and enhancing the quality of care for chest trauma patients. Results The mechanism of injury in all cases of chest injuries was blunt trauma, accounting for 100% of the cases. The specific mechanisms of injury observed in the study included falls from standing, falls from height, road traffic collisions, and assault. The study comprised 139 individuals, 128 of whom were diagnosed with rib fractures, and 11 who did not have any rib fractures. In addition, two patients were hospitalized with bilateral rib fractures, both of which were life-threatening. Tragically, one of these cases resulted in the death of the patient. With regard to outcomes, 67% of the patients received a consultation at Royal Stoke Hospital (RSH). Eight individuals were transferred to RSH for further management, while the remaining 131 patients were not transferred. Eighty-seven individuals were discharged from the hospital, indicating successful recovery and readiness for discharge. However, it is noteworthy that nine patients experienced complications during their hospital stay, highlighting the potential challenges and risks associated with chest trauma management. Tragically, seven patients succumbed to their injuries and passed away.  Conclusions The majority of patients in this study were aged 65 and over and presented with multiple comorbidities, indicating the complex medical profile of this population. However, despite the presence of life-threatening injuries and the associated risks, only a minority of patients in the study were transferred to a designated trauma centre. This raises concerns about the adequacy of the current transfer protocols and the potential impact on patient outcomes.

Design and Development of an Objective Evaluation System for a Web-Based Simulator for Trauma Management

BACKGROUND

Trauma injuries are one of the main leading causes of death in the world. Training with guidelines and protocols is adequate to provide a fast and efficient treatment to patients that suffer a trauma injury.

OBJECTIVES

This study aimed to evaluate deviations from a set protocol, a new set of metrics has been proposed and tested in a pilot study.

METHODS

The participants were final-year students from the Universidad Autónoma de Madrid and first-year medical residents from the Hospital Universitario La Paz. They were asked to train four trauma scenarios with a web-based simulator for 2 weeks. A test was performed pre-training and another one post-training to evaluate the evolution of the treatment to those four trauma scenarios considering a predefined trauma protocol and based on the new set of metrics. The scenarios were pelvic and lower limb traumas in a hospital and in a prehospital setting, which allow them to learn and assess different trauma protocols.

RESULTS

The results show that, in general, there is an improvement of the new metrics after training with the simulator.

CONCLUSION

These new metrics provide comprehensive information for both trainers and trainees. For trainers, the evaluation of the simulation is automated and contains all relevant information to assess the performance of the trainee. And for trainees, it provides valuable real-time information that could support the trauma management learning process.

A Prospective Observational Study on the Outcome Assessment of Conservative Management Versus Intercostal Drainage (ICD) in Blunt Chest Injury Patients With ≤3 Rib Fractures in a North Indian Tertiary Care Center

Introduction Trauma is the third most common cause of death in all age groups. One out of four trauma patients die due to thoracic injury or its complications. Seventy percent of thoracic traumas are due to blunt injury. This indicates the importance of chest trauma among all traumas. Quick and precise assessment bears paramount importance in deciding life-saving and definitive management. Often, the initial management in blunt injury patients is based on subjective assessment by the attending clinician. A scoring system that provides early identification of the patients at the greatest risk for respiratory failure and more likely to require mechanical ventilation and require prolonged care, as well as those with a higher mortality risk, may allow the early institution of intervention to improve outcomes. Thoracic Trauma Severity Score (TTSS) poses to be a precise tool in directing the management modality to be employed. Methodology This was an observational study including 112 patients of age >12 years, with blunt chest injury, sustaining ≤3 rib fractures, and with a stable chest wall. The patients with penetrating injury, those with blunt chest injury having flail segment, patients in the pediatric age group (<12 years), or polytrauma patients were excluded from our study. Of the 112 patients, 56 had been managed by intercostal drainage (ICD), and the rest (56) had been managed conservatively. Result Road traffic accidents (RTA) were the most common mode of injury in both groups. The percentage of the patients with one, two, and three rib fractures was 57.14%, 32.14%, and 10.71%, respectively, in the ICD group and 85.71%, 7.14%, and 7.14%, respectively, in the conservative management group (p = 0.124). The mean TTSS score was significantly more in the ICD group as compared to the conservative management group in the single rib fracture patients (p = 0.001*), as well as all patients of any number of rib fractures (p < 0.01*) (significance was defined as a value of p less than 0.05 {indicated by an asterisk}). The mean hospital stay was significantly lower in the conservative group as compared to the ICD group (p < 0.01*). The mean SF-36 (outcome) was significantly more in the conservative management group as compared to the ICD group (p = 0.020*). The mean cost of treatment was significantly more in the ICD group as compared to the conservative management group (p < 0.001*). Conclusion In our study, a TTSS (as measured by the primary care surgeon) of >7, across any number of rib fractures, was preferably predictive of management by ICD, while a <7 value was favorable for conservative management. TTSS can be used as an important tool to predict the management modality in blunt chest injury patients with ≤3 rib fractures.

The Implementation of a Rib Fracture Pathway at a Small District General Hospital to Improve Patient Care

Background and objective Rib fractures are common presentations to the emergency department following blunt thoracic trauma. Despite this injury causing significant morbidity and mortality, no national guidelines exist to guide the acute management of this condition. In light of this, this quality improvement project was conducted at a district general hospital (DGH) with the aim of assessing the impact of using a simple rib fracture management pathway. Methods A retrospective review of paper notes and electronic databases of patients with a recorded diagnosis of "rib fractures" were reviewed. Following this, a management pathway was designed and then implemented, which incorporated BMJ Best Practices and local hospital needs. The study then assessed the impact of the pathway. Results Prior to implementing the pathway, a total of 47 individual patients were included in the statistical analysis. Of the patients analysed, 44% were older than 65 years. Of note, 89% received regular paracetamol for analgesia, 41% received regular nonsteroidal anti-inflammatory drugs (NSAIDs), and 69% received regular opioids. Advanced analgesics such as patient-controlled analgesia (PCA) and nerve blocks were poorly used; for instance, a PCA was used in only 13% of cases. Only 6% of patients received daily pain team reviews and only 44% of patients were seen by physiotherapists within the first 24 hours. Additionally, 93% of patients who were admitted under general surgery had a STUMBL (STUdy of the Management of BLunt chest wall trauma) prognostic score >10. Post-pathway implementation, a total of 22 individual patients were included in the statistical analysis. Of them, 52% were older than 65 years. The use of simple analgesia was unchanged. However advanced analgesia was better escalated, and PCAs were used 43% of the time. The involvement of other healthcare professionals improved; 59% were reviewed by the pain team in the first 24 hours, 45% received daily pain team reviews, and 54% received advanced analgesia. Conclusion Based on our findings, implementing a simple rib fracture pathway is effective at improving the management of rib fracture patients admitted to our DGH.

Utility of an Emergency Department Observation Unit in Providing Care for Patients With Blunt Thoracic Trauma

Background The use of Emergency Department Observation Units (EDOUs) to treat patients with a variety of complaints has grown over recent years. However, the treatment of patients with traumatic injuries in EDOUs is infrequently described. Our study sought to describe the feasibility of treating patients with blunt thoracic trauma in an EDOU in consultation with our trauma and acute care surgery (TACS) team. Together, our Emergency Department (ED) and TACS teams designed a protocol for the treatment of patients with specific blunt thoracic injuries (fewer than three rib fractures, nondisplaced sternal fractures) that we felt would require less than 24 hours of care in a hospital setting. Methods This study is an IRB-approved retrospective analysis comparing two groups before (pre-EDOU) and after (EDOU) the creation of the EDOU protocol, which was implemented in August 2020. Data was collected at a single, Level 1 trauma center with approximately 95,000 annual visits. Similar inclusion and exclusion criteria were used to select patients in both groups. We conducted two-sample t-tests and Chi-square testing to assess for significance. Primary outcomes include length of stay and bounce-back rate. Results A total of 81 patients were included in our data set across both groups. Forty-three patients were included in our pre-EDOU group while 38 patients were treated in our EDOU once the protocol was implemented. Patients in both groups were of similar age, gender and had similar Injury Severity Scores (ISS) ranging from 9 to 14. Hospital length of stay was shorter for the EDOU group (31.5 hours) compared to the pre-EDOU group (36.4 hours) although not statistically significant. When risk stratified by ISS, hospital length of stay did reach statistical significance and was found to be shorter for patients with ISS scores greater than or equal to 9 that were treated in the EDOU (29.1 hours vs. 43.8 hours, p = .028). Both groups had one patient each bounce back for repeat evaluation and additional care. Conclusion This study demonstrates the potential use of EDOUs to treat patients with mild to moderate blunt thoracic injuries. The availability of trauma surgeons for consultation along with ED provider experience may be rate-limiting steps in utilizing observation units to care for trauma patients. Additional research with more participants is needed to determine the impact of implementing such a practice at other institutions.

Early non-invasive ventilation and high-flow nasal oxygen therapy for preventing endotracheal intubation in hypoxemic blunt chest trauma patients: the OptiTHO randomized trial

BACKGROUND

The benefit-risk ratio of prophylactic non-invasive ventilation (NIV) and high-flow nasal oxygen therapy (HFNC-O₂) during the early stage of blunt chest trauma remains controversial because of limited data. The main objective of this study was to compare the rate of endotracheal intubation between two NIV strategies in high-risk blunt chest trauma patients.

METHODS

The OptiTHO trial was a randomized, open-label, multicenter trial over a two-year period. Every adult patients admitted in intensive care unit within 48 h after a high-risk blunt chest trauma (Thoracic Trauma Severity Score ≥ 8), an estimated PaO₂/FiO₂ ratio < 300 and no evidence of acute respiratory failure were eligible for study enrollment (Clinical Trial Registration: NCT03943914). The primary objective was to compare the rate of endotracheal intubation for delayed respiratory failure between two NIV strategies: i) a prompt association of HFNC-O₂ and "early" NIV in every patient for at least 48 h with vs. ii) the standard of care associating COT and "late" NIV, indicated in patients with respiratory deterioration and/or PaO₂/FiO₂ ratio ≤ 200 mmHg. Secondary outcomes were the occurrence of chest trauma-related complications (pulmonary infection, delayed hemothorax or moderate-to-severe ARDS).

RESULTS

Study enrollment was stopped for futility after a 2-year study period and randomization of 141 patients. Overall, 11 patients (7.8%) required endotracheal intubation for delayed respiratory failure. The rate of endotracheal intubation was not significantly lower in patients treated with the experimental strategy (7% [5/71]) when compared to the control group (8.6% [6/70]), with an adjusted OR = 0.72 (95%IC: 0.20-2.43), p = 0.60. The occurrence of pulmonary infection, delayed hemothorax or delayed ARDS was not significantly lower in patients treated by the experimental strategy (adjusted OR = 1.99 [95%IC: 0.73-5.89], p = 0.18, 0.85 [95%IC: 0.33-2.20], p = 0.74 and 2.14 [95%IC: 0.36-20.77], p = 0.41, respectively).

CONCLUSION

A prompt association of HFNC-O₂ with preventive NIV did not reduce the rate of endotracheal intubation or secondary respiratory complications when compared to COT and late NIV in high-risk blunt chest trauma patients with non-severe hypoxemia and no sign of acute respiratory failure.

CLINICAL TRIAL REGISTRATION

NCT03943914, Registered 7 May 2019.

Shock Index for the Prediction of Interventions and Mortality in Patients With Blunt Thoracic Trauma

INTRODUCTION

Shock index (SI) is a bedside simple scoring tool; however, it has not yet been tested in blunt thorax trauma (BTT). We sought to evaluate the prognostic value of SI for chest interventions (thoracostomy tube or thoracotomy), blood transfusion, and mortality in patients with BTT. We hypothesized that high SI is associated with worse outcomes in patients with BTT.

METHODS

We conducted a retrospective analysis of all BTT patients (chest Abbreviated Injury Score [AIS] > 1) hospitalized in a level 1 trauma center between 2011 and 2020. Patients with AIS >1 for head or abdominal injuries and patients undergoing open reduction and internal fixation surgery or penetrating injuries were excluded. Patients were categorized into two groups (low SI <0.80 versus high SI ≥0.80) based on the receiver operating characteristic curve analysis. Multivariable regression analysis was performed to identify the predictors of mortality.

RESULTS

A total of 1645 patients were admitted with BTT; of them, 24.5% had high SI. The mean age was 39.2 ± 15.2 y, and most were males (91%). Patients with high SI were younger, had sustained severer injuries, and required more chest interventions (P = 0.001), blood transfusion (P = 0.001), and massive transfusion protocol activation (P = 0.001) compared with low SI group. The overall in-hospital mortality rate was 2.6%, which was more in the high SI group (8.2% versus 0.8%; P = 0.001). SI significantly correlated with age (r = -0.281), injury severity score (r = 0.418), Glasgow Come Score on arrival (r = -0.377), Trauma and Injury Severity Score (r = -0.144), Revised Trauma Score (r = -0.219), serum lactate (r = 0.434), blood transfusion units (r = 0.418), and chest AIS (r = 0.066). SI was an independent predictor of mortality (odds ratio 3.506; 95% confidence interval 1.389-8.848; P = 0.008), and this effect persisted after adjustment for chest intervention (odds ratio 2.923; 95% confidence interval 1.146-7.455; P = 0.02).

CONCLUSIONS

The present study highlights the prognostic value of SI as a rapid bedside tool to predict the use of interventions and the risk of mortality in patients with BTT. The study findings help the emergency physicians for early and appropriate risk stratification and triaging of patients with BTT.

Effect of coolant spray on rib fracture pain of geriatric blunt thoracic trauma patients: a randomized controlled trial

OBJECTIVE

This study aimed to evaluate the effectiveness of cryotherapy in elderly patients with rib fractures due to blunt thoracic trauma.

METHODS

In this prospective randomized controlled study, geriatric patients were assigned to groups to receive either coolant spray (n=51) or placebo spray (n=50). The visual analog scale scores of all patients were recorded before starting spray application (V0), as well as at 10th (V1), 20th (V2), 30th (V3), 60th (V4), 120th (V5), and 360th (V6) minute. The mean decreases in the visual analog scale scores were calculated.

RESULTS

The differences between V0 and V1, V0 and V2, V0 and V3, and V0 and V4 mean visual analog scale scores measured in the coolant spray group were found to be significantly higher (p<0.001). In V1, V2, V3, and V4 measurements, the incidence of "clinical effectiveness" in the coolant spray group was significantly higher than in the placebo group (p=0.001).

CONCLUSIONS

Coolant spray therapy can be used as a component of multimodal therapy to provide adequate analgesia due to rib fractures in geriatric patients.

A retrospective validation study of the STUMBL score for emergency department patients with blunt thoracic trauma

INTRODUCTION

Blunt thoracic trauma (BTT) is a leading cause of emergency department (ED) trauma-related attendance. Risk prediction tools are commonly to predict patients' outcomes and assign them to the most appropriate care setting. The STUMBL score is a prognostic model for BTT, derived and validated in the United Kingdom; items comprising the score are age, number of rib fractures, use of pre-injury anticoagulants, chronic lung disease and oxygen saturation levels. This study's aim was to validate the STUMBL score in an Italian ED.

METHODS

This single-centre retrospective validation study was conducted in the ED of Santa Croce and Carle hub hospital in Cuneo, north-western Italy. All patients with an ED attendance for isolated BTT from 2018 to 2021 were included. Exclusion criteria were an age of under eighteen and the presence of any immediately life-threatening lesion. The primary outcome was the development of trauma-related complications, defined by the occurrence of one or more of the following: in-hospital mortality, pulmonary complications (infection, pleural effusion, haemothorax, pneumothorax, pleural empyema), need for intensive care unit admission, hospital length of stay equal to or greater than seven days. The performance of the STUMBL score was analysed in terms of discrimination with the evaluation of the receiver operating characteristic curve and calibration with the Hosmer-Lemeshow test and with the calibration belt.

RESULTS

745 patients were enroled (median age 64 [25th;75th percentile: 50;78], male/female ratio 1:4, median Charlson comorbidity index 2 [1;4], median STUMBL score 11 [6;17]). 65.2% of patients were discharged home after ED evaluation. 203 patients (27.2%) developed the primary outcome. The STUMBL score was significantly different in patients with complications compared to those without complications (9 [5;13] vs 21 [17;25], p < 0.001). The C index of the score for the primary outcome was 0.90 (95% CI 0.88-0.93), and the result of the Hosmer-Lemeshow test was 9.01 (p = 0.34). STUMBL score = 16 has a sensitivity of 0.80 (95% CI 0.75-0.85), specificity of 0.87 (95% CI 0.84-0.90), a positive predictive value of 0.70 (95% CI 0.64-0.76), and a negative predictive value of 0.92 (95% CI 0.90-0.94).

CONCLUSION

In this validation study, the STUMBL score demonstrated excellent discrimination and calibration in predicting the outcome of patients attending the ED with a BTT.

Risk factors that predict mortality in patients with blunt chest wall trauma: an updated systematic review and meta-analysis

BACKGROUND

Over the last 10 years, research has highlighted emerging potential risk factors for poor outcomes following blunt chest wall trauma. The aim was to update a previous systematic review and meta-analysis of the risk factors for mortality in blunt chest wall trauma patients.

METHODS

A systematic review of English and non-English articles using MEDLINE, Embase and Cochrane Library from January 2010 to March 2022 was completed. Broad search terms and inclusion criteria were used. All observational studies were included if they investigated estimates of association between a risk factor and mortality for blunt chest wall trauma patients. Where sufficient data were available, ORs with 95% CIs were calculated using a Mantel-Haenszel method. Heterogeneity was assessed using the I² statistic.

RESULTS

73 studies were identified which were of variable quality (including 29 from original review). Identified risk factors for mortality following blunt chest wall trauma were: age 65 years or more (OR: 2.11; 95% CI 1.85 to 2.41), three or more rib fractures (OR: 1.96; 95% CI 1.69 to 2.26) and presence of pre-existing disease (OR: 2.86; 95% CI 1.34 to 6.09). Other new risk factors identified were: increasing Injury Severity Score, need for mechanical ventilation, extremes of body mass index and smoking status. Meta-analysis was not possible for these variables due to insufficient studies and high levels of heterogeneity.

CONCLUSIONS

The results of this updated review suggest that despite a change in demographics of trauma patients and subsequent emerging evidence over the last 10 years, the main risk factors for mortality in patients sustaining blunt chest wall trauma remained largely unchanged. A number of new risk factors however have been reported that need consideration when updating current risk prediction models used in the ED.

PROSPERO REGISTRATION NUMBER

CRD42021242063. Date registered: 29 March 2021. https://www.crd.york.ac.uk/PROSPERO/%23recordDetails.

The Need for Trauma Management Training and Evaluation on a Prehospital Setting

Trauma is one of the leading causes of death in the world, being the main cause of death in people under 45 years old. The epidemiology of these deaths shows an important peak during the first hour after a traumatic event. Therefore, learning how to manage traumatic injuries in a prehospital setting is of great importance. Medical students from Universidad Autónoma performed 66 different simulations to stabilize a trauma patient on a prehospital scene by using a web-based trauma simulator. Then, a panel of trauma experts evaluated the simulations performed, observing that, on average, an important number of simulations were scored below 5, being the score values provided from 0, minimum, to 10, maximum. Therefore, the first need detected is the need to further train prehospital trauma management in undergraduate education. Additionally, a deeper analysis of the scores provided by the experts was performed. It showed a great dispersion in the scores provided by the different trauma experts per simulation. Therefore, a second need is identified, the need to develop a system to objectively evaluate trauma management.

Erector spinae plane block for affective and safe analgesia in a patient with severe penetrating chest trauma caused by an explosion in the battlefield

The ongoing conflict in Ukraine continues to generate many complex traumatic injuries and provides unique challenges to anaesthesiologists who provide medical care at various levels of medical evacuation. We report the successful use of an ultrasound‐guided continuous erector spinae plane (ESP) block in a patient with severe posterolateral chest trauma. The acute perioperative outcome of the patient was improved with the ESP block, the main benefits being excellent analgesia and minimal postoperative morphine requirements without influencing the risk of bleeding and coagulopathy. We conclude that continuous ESP block can be utilized to provide excellent analgesia following massive thoracic trauma. It's ease of placement under ultrasound guidance and low risk of complications makes this technique particularly useful in war medicine.

High flow nasal cannula outside the ICU provides optimal care and maximizes hospital resources for patients with multiple rib fractures

BACKGROUND

High flow nasal cannula (HFNC) use reduces work of breathing and improves oxygenation for patients with hypoxemic respiratory failure. Limited prior work has explored protocolized use of HFNC for trauma patients outside the Intensive Care Unit (ICU). The purpose of this study is to describe and evaluate use of HFNC for patients with rib fractures when therapy was standard of care on all floors of the hospital.

METHODS

In 2018, the study hospital expanded use of HFNC (AIRVO; Fisher Paykel, Auckland, NZ) to all floors of the hospital, making it available in the ICU, Emergency Department (ED), and on general inpatient floors. The study group included adult patients with three or more rib fractures who received HFNC at any location in the hospital (Phase 2: January 2018-December 2019). The study group was compared to a historical control group when HFNC was available only in the ICU (Phase 1: March 2013-July 2015). Patients were excluded from the study if they received invasive mechanical ventilation prior to HFNC. Primary outcomes were mechanical ventilation rates, ICU days, length of hospitalization, and mortality.

RESULTS

During the study period, 63 patients received HFNC, with 35% of patients (n = 22) receiving the duration of therapy outside the ICU. When compared to the control group (N = 63), there were no significant differences in total hospital days (9 vs. 9, p=.64), mechanical ventilation (19% vs. 13%, p=.47), or mortality (3% vs. 5%, p = 1.00). Twenty-seven percent of patients (n = 17) in the study group avoided the ICU during hospitalization.

CONCLUSIONS

Findings suggest that HFNC therapy can be safely initiated and managed on all hospital floors for patients with multiple rib fractures. Making the therapy available outside the ICU may reduce healthcare resource use without adversely affecting patient outcomes.

Effect of an intervention for patients 65 years and older with blunt chest injury: Patient and health service outcomes

INTRODUCTION

Blunt chest injury in older adults, aged 65 years and older, leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes in older adults with blunt chest injury.

METHODS

ChIP comprised multidimensional implementation guidance in three key pillars of care for blunt chest injury: respiratory support, analgesia, and complication prevention. Implementation was guided using the Behaviour Change Wheel. This proof-of-concept controlled pre- and post-test study with two intervention and two control sites in Australia was conducted from July 2015 to June 2019. The primary outcomes were non-invasive ventilation (NIV) use, unplanned Intensive Care Unit (ICU) admissions, and in-hospital mortality. Secondary outcomes were health service and costing outcomes.

RESULTS

There were 1122 patients included in the analysis, with 673 at intervention sites (331 pre-test and 342 post-test) and 449 at control sites (256 pre-test and 193 post-test). ChIP was associated with unplanned ICU admissions and in NIV use with a reduction of the odds in the post vs the pre periods in the intervention sites when compared to the controls (ratio of OR=0.13, 95%CI=0.03-0.55) and (ratio of OR=0.14, 95%CI=0.02-0.98) respectively. There was no significant change in mortality. Implementing ChIP was also associated with health service team reviews with an increased odds in the post vs pre periods in the intervention sites in comparison to the controls for surgical review (ratio of OR =6.93, 95%CI=4.70-10.28), ICU doctor (ratio of OR =5.06, 95%CI=2.26-9.25), ICU liaison (ratio of OR =14.14, 95%CI=3.15-63.31), and pain (ratio of OR =5.59, 95%CI=3.25-9.29). ChIP was also related to incentive spirometry (ratio of OR=6.35, 95%CI= 3.15-12.82) and overall costs (ratio of mean ratio=1.34, 95%CI=1.09-1.66) with a higher ratio for intervention sites.

CONCLUSION

Implementation of ChIP using the Behaviour Change Wheel was associated with reduced unplanned ICU admissions and NIV use and improved health care delivery.

TRIAL REGISTRATION

ANZCTR: ACTRN12618001548224, approved 17/09/2018.

Implementation of a chest injury pathway in the emergency department

Rib fractures represent a substantial health burden. Chest injuries contribute to 25% of deaths after trauma and survivors can experience long-standing consequences, such as reduced functional capabilities and loss of employment. Over recent years, there has been an increase in the awareness of the importance of early identification, aggressive pain management and adequate safety netting for patients with chest injuries. Substandard management leads to increased rates of morbidity and mortality. The development of protocols in the emergency department (ED) for management of patients with chest wall injuries has demonstrated reduction of complication rates.

Our aim was to develop an evidence-based, multidisciplinary chest injury pathway for the management of patients presenting with rib injury to our ED.

Prior to implementation of the pathway in our department, only 39% of patients were documented as having received analgesia and only 7% of discharged patients had documented written verbal advice. There was no standardised method to perform regional anaesthetic blocks. Using quality improvement methods, we standardised imaging modality, risk stratification with a scoring system, analgesia with emphasis on regional anaesthesia blocks and disposition with information leaflets for those discharged.

Implementation of the pathway increased rates of documented analgesia received from 39% to 70%. The number of regional anaesthetic blocks performed went from 0% to 60% and the number of patients receiving discharge advice went from 7% to 70%. Compliance of doctors and nurses with the pathway was 63%.

Our previous audits showed substandard management of patients with chest injuries in our department. Through this quality improvement project, we were able to improve the quality of care provided to patients attending with rib fractures by increasing rate of analgesia received, regional blocks performed and discharge advice given.

Comparison of Infectious Complications after Surgical Fixation versus Epidural Analgesia for Acute Rib Fractures

Background: Surgical stabilization of rib fractures (SSRF) is associated with decreased mortality and respiratory complications. Patients who are not offered SSRF are often treated with epidural analgesia (EA) to reduce pain and improve pulmonary mechanics. We sought to compare infectious complications in patients undergoing either SSRF or EA. We hypothesized that infectious complications are equivalent between the two treatment groups. Patients and Methods: We performed a retrospective cohort study of adult trauma patients with acute rib fractures within the Trauma Quality Improvement Program (TQIP) 2017 dataset and used International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify patients who underwent SSRF or EA. We excluded patients who received both treatments in the same admission. Our primary outcome was the development of sepsis. Secondary outcomes were specific infections including ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), and central line-associated blood stream infections (CLABSI). Multiple logistic regression analyses were used to adjust for age, injury severity score (ISS), chest Abbreviated Injury Scale (AIS), flail chest, traumatic brain injury (TBI), and comorbidities. Results: We identified 2,252 and 1,299 patients who underwent SSRF and EA, respectively. Patients with SSRF were younger with higher ISS and longer length of stay (LOS). There was no difference in mortality, however, SSRF had higher rate of sepsis (1.6% vs. 0.5%; p = 0.001), VAP (5.1% vs. 0.9%; p < 0.001), CAUTI (1.7% vs. 0.5%; p = 0.001), and CLABSI (0.2% vs. 0%; p = 0.05). On multiple regression, SSRF was associated with higher odds of sepsis (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.04-6.63), CAUTI (OR, 2.96; 95% CI, 1.11-7.88), and VAP (OR, 3.24; 95% CI, 1.73-6.06). Among those who developed sepsis, there was no significant difference in mortality or LOS between groups. Conclusions: Despite no difference in mortality, SSRF was associated with increased risk of septic complications in patients with rib fractures compared to epidural analgesia. Identifying, and addressing, risk factors of sepsis in this patient population is a critical performance improvement process to optimize outcomes without increased adverse events.

Effect of the presence of rib fracture on mortality and morbidity in blunt thoracic traumas

BACKGROUND

The aim of this study was to determine the effect of the presence of rib fracture on mortality and morbidity in blunt thoracic trauma (BTT).

METHODS

Records of patients aged over 18 and admitted with BTT between January 2017 and October 2019 dates were ret-rospectively evaluated. Only patients with both BTT and rib fracture were included in the study. Age, gender, trauma mechanism, additional organ injuries, and need for intensive care unit of patients were identified. The total length of hospital stay, length of stay in the intensive care unit, treatment modalities, need for mechanical ventilator; blood and blood products, complications, and mortality rates for patients were recorded.

RESULTS

One hundred eighty-six (73.8%) and 66 (26.2%) of 252 included patients were male and female, respectively. The most commonly seen trauma mechanism was motor vehicle accidents (51.4%). The mean age of patients was 52±12 (18-91). We identified that there was a significant association between hemothorax and non-thoracic additional organ injuries (p=0.024). There was no significant association between pneumothorax and additional organ injuries (p=0.067). The number of fractured ribs was significantly different between cases with and without hemothorax (p<0.001). There was also a significant difference between cases with and without pneumothorax in terms of the number of broken ribs (p<0.039). There was a significant difference between cases undergone thoracotomy and cases who did not undergo thoracotomy in terms of mean length of stay in the hospital (p<0.001). There was a positive correlation between the number of broken ribs and length of stay in the hospital (r=320, p<0.001).

CONCLUSION

Increased number of rib fracture in BTTs increases morbidity and length of stay in the hospital.

Biomechanical study of embracing and non-embracing rib plates

The study was carried out to explore the biomechanical properties of embracing and non-embracing rib plates. Forty-eight adult cadaver rib specimens were divided randomly into six groups: three fixation model groups were made using embracing plates (two pairs of equals on both sides of the broken end), and the other three groups were fixed with a pre-shaped anatomical plate (three locking screws on each side of the end were equally spaced). The biomechanical properties of these models were analyzed using non-destructive three-point bending tests, non-destructive torsion experiments, and destructive axial compression tests. In this study, the gap of fracture ends was widened in embracing plate group in the non-destructive three-point bending experiment. No change in the fracture ends was detected in the pre-shaped anatomical plate group. The bending stress of the pre-shaped anatomical plate group was significantly enhanced at the 2-12 mm displacement points (p < 0.05). Moreover, there was no significant difference in torque noticed between the two groups in the torsion experiment (p = 0.082). In the destructive axial compression experiment, the load index of the two groups were higher than the normal physiological load, suggesting that both materials could provide sufficient strength for rib fractures. The pre-shaped anatomical plate displayed more reliable attachment in terms of stability, bending, and load. Our results indicated that the embracing plate has the advantage of fretting at the fracture end.

Effect of Positive Expiratory Pressure Therapy on Lung Volumes and Health Outcomes in Adults With Chest Trauma: A Systematic Review and Meta-Analysis

OBJECTIVE

The purposes of this study were to evaluate the effect of positive expiratory pressure (PEP) therapy on lung volumes and health outcomes in adults with chest trauma and to investigate any adverse effects and optimal dosages leading to the greatest positive impact on lung volumes and recovery.

METHODS

Data sources were MEDLINE/PubMed, Embase, Cochrane Library, Physiotherapy Evidence Database, CINAHL, Open Access Thesis/Dissertations, EBSCO Open Dissertations, and OpenSIGLE/Open Grey. Randomized controlled trials investigating PEP therapy compared with usual care or other physical therapist interventions were included. Participants were >18 years old and who were admitted to the hospital with any form of chest trauma, including lung or cardiac surgery, blunt chest trauma, and rib fractures. Methodological quality was assessed using the Physiotherapy Evidence Database Scale, and the level of evidence was downgraded using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Eleven studies involving 661 participants met inclusion eligibility. There was very low-level evidence that PEP improved forced vital capacity (standardized mean difference = -0.50; 95% CI = -0.79 to -0.21), forced expiratory volume in 1 second (standardized mean difference = -0.38; 95% CI = -0.62 to -0.13), and reduced the incidence of pneumonia (relative risk = 0.16; 95% CI = 0.03 to 0.85). Respiratory muscle strength also significantly improved in all 3 studies reporting this outcome. There was very low-level evidence that PEP did not improve other lung function measures, arterial blood gases, atelectasis, or hospital length of stay. Both PEP devices and dosages varied among the studies, and no adverse events were reported.

CONCLUSION

PEP therapy is a safe intervention with very low-level evidence showing improvements in forced vital capacity, forced expiratory volume in 1 second, respiratory muscle strength, and incidence of pneumonia. It does not improve arterial blood gases, atelectasis, or hospital length of stay. Because the evidence is very low level, more rigorous physiological and dose-response studies are required to understand the true impact of PEP on the lungs after chest trauma.

IMPACT

There is currently no strong evidence for physical therapists to routinely use PEP devices following chest trauma. However, there is no evidence of adverse events; therefore, in specific clinical situations, PEP therapy may be considered.

A survey of current practice in UK emergency department management of patients with blunt chest wall trauma not requiring admission to hospital

INTRODUCTION

There is no universal agreement or supporting evidence for the content or format of a standardised guidance document for patients with blunt chest wall trauma. The aim of this study is to investigate current UK Emergency Medicine practice of the management of patients with blunt chest wall trauma, who do not require admission to hospital.

METHODS

This was a cross-sectional survey study, with mixed quantitative / qualitative analysis methods. A convenience sample of all professions working in the Emergency Departments / Urgent Care Centres in the UK was used. A combination of closed and open-ended questions were included, covering demographics and current practice in the respondent's main place of work. Themes explored included management strategies for safe discharge home, risk prediction and variables considered relevant for inclusion in patient guidance.

RESULTS

A total of 113 clinicians responded from all UK trauma networks, including all devolved nations. A total of 20 different risk prediction tools / pathways were reported to be used when assessing whether a patient is safe for discharge home, with over 35 different variables listed by respondents as being important to highlight to patients. Qualitative analysis revealed that a small number of respondents believe patients can be better managed through the improvement of the following; identification of the high-risk patient, initial assessment and current management strategies used in the ED / UCC.

DISCUSSION

The wide variation in practice highlighted in this study may be due in part to a lack of national consensus guidelines on how to manage this complex patient group. Further research is needed into whether structured national guidelines for the assessment and management of such patients could potentially lead to an overall improvement in outcomes. Such guidelines should be developed by not only expert clinicians and researchers, but also and more importantly by those service-users who have lived experience of blunt chest wall trauma.

Building consensus on inpatient discharge pathway components in the management of blunt thoracic injuries: An e-Delphi study amongst an international professional expert panel

INTRODUCTION

Access to a standardised and evidence informed approach to blunt thoracic injury (BTI) management remains challenging across organised trauma systems globally. It remains important to optimise recovery through pathway-based interventions. The aim of this study was to identify components of care that are important in the effective discharge process for patients with BTI and pinpoint core and optional components for a patient pathway-based intervention.

METHODS

Components of care within the hospital discharge process after BTI were identified using existing literature and expert opinion. These initial data were entered into a three-round e-Delphi consensus method where round one involved further integrating and categorising components of discharge care from the expert panel. The panel comprised of an international interdisciplinary group of healthcare professionals with experience in the management of BTI. All questionnaires were completed anonymously using an online survey and involved rating care components using Likert scales (Range: 1-6). The final consensus threshold for pathway components were defined as a group rating of greater than 70% scoring in either the moderate importance (3-4) or high importance category (5-6) and less than 15% of the panel scoring within the low importance category (1-2).

RESULTS

Of 88 recruited participants, 67 (76%) participated in round one. Statements were categorised into nine themes: (i) Discharge criteria; (ii) Physical function and Self-care; (iii) Pain management components; (iv) Respiratory function components; (v) General care components; (vi) Follow-up; (vii) Psychological care components; (viii) Patient, family and communication; (ix) 'Red Flag' signs and symptoms. Overall, 70 statements were introduced into the consensus building exercise in round two. In round three, 40 statements from across these categorises achieved consensus amongst the expert panel, forming a framework of core and optional care components within the discharge process after BTI.

CONCLUSIONS

These data will be used to build a toolkit containing guidance on developing discharge pathways for patients with BTI and for the development of audit benchmarks for analysing healthcare provision in this area. It is important that interventions developed using this framework are validated locally and evaluated for efficacy using appropriate research methodology.

Prospective observational study to examine health-related quality of life and develop models to predict long-term patient-reported outcomes 6 months after hospital discharge with blunt thoracic injuries

OBJECTIVE

This study aimed to examine the long-term outcomes and health-related quality of life in patients with blunt thoracic injuries over 6 months from hospital discharge and develop models to predict long-term patient-reported outcomes.

DESIGN

A prospective observational study using longitudinal survey design.

SETTING

The study recruitment was undertaken at 12 UK hospitals which represented diverse geographical locations and covered urban, suburban and rural areas across England and Wales.

PARTICIPANTS

337 patients admitted to hospital with blunt thoracic injuries were recruited between June 2018-October 2020.

METHODS

Participants completed a bank of two quality of life surveys (Short Form-12 (SF-12) and EuroQol 5-Dimensions 5-Levels) and two pain questionnaires (Brief Pain Inventory and painDETECT Questionnaire) at four time points over the first 6 months after discharge from hospital. A total of 211 (63%) participants completed the outcomes data at 6 months after hospital discharge.

OUTCOMES MEASURES

Three outcomes were measured using pre-existing and validated patient-reported outcome measures. Outcomes included: Poor physical function (SF-12 Physical Component Score); chronic pain (Brief Pain Inventory Pain Severity Score); and neuropathic pain (painDETECT Questionnaire).

RESULTS

Despite a trend towards improving physical functional and pain at 6 months, outcomes did not return to participants perceived baseline level of function. At 6 months after hospital discharge, 37% (n=77) of participants reported poor physical function; 36.5% (n=77) reported a chronic pain state; and 22% (n=47) reported pain with a neuropathic component. Predictive models were developed for each outcome highlighting important data collection requirements for predicting long-term outcomes in this population. Model diagnostics including calibration and discrimination statistics suggested good model fit in this development cohort.

CONCLUSIONS

This study identified the recovery trajectories for patients with blunt thoracic injuries over the first 6 months after hospital discharge and present prognostic models for three important outcomes which after external validation could be used as clinical risk stratification scores.

Implementation of a hospital-wide multidisciplinary blunt chest injury care bundle (ChIP): Fidelity of delivery evaluation

BACKGROUND

Ineffective intervention for patients with blunt chest wall injury results in high rates of morbidity and mortality. To address this, a blunt chest injury care bundle protocol (ChIP) was developed, and a multifaceted plan was implemented using the Behaviour Change Wheel.

OBJECTIVE

The purpose of this study was to evaluate the reach, fidelity, and dose of the ChIP intervention to discern if it was activated and delivered to patients as intended at two regional Australian hospitals.

METHODS

This is a pretest and post-test implementation evaluation study. The proportion of ChIP activations and adherence to ChIP components received by eligible patients were compared before and after intervention over a 4-year period. Sample medians were compared using the nonparametric median test, with 95% confidence intervals. Differences in proportions for categorical data were compared using the two-sample z-test.

RESULTS/FINDINGS

Over the 19-month postimplementation period, 97.1% (n = 440) of eligible patients received ChIP (reach). The median activation time was 134 min; there was no difference in time to activation between business hours and after-hours; time to activation was not associated with comorbidities and injury severity score. Compared with the preimplementation group, the postimplementation group were more likely to receive evidence-based treatments (dose), including high-flow nasal cannula use (odds ratio [OR] = 6.8 [95% confidence interval {CI} = 4.8-9.6]), incentive spirometry in the emergency department (OR = 7.5, [95% CI = 3.2-17.6]), regular analgesia (OR = 2.4 [95% CI = 1.5-3.8]), regional analgesia (OR = 2.8 [95% CI = 1.5-5.3]), patient-controlled analgesia (OR = 1.8 [95% CI = 1.3-2.4]), and multiple specialist team reviews, e.g., surgical review (OR = 9.9 [95% CI = 6.1-16.1]).

CONCLUSIONS

High fidelity of delivery was achieved and sustained over 19 months for implementation of a complex intervention in the acute context through a robust implementation plan based on theoretical frameworks. There were significant and sustained improvements in care practices known to result in better patient outcomes. Findings from this evaluation can inform future implementation programs such as ChIP and other multidisciplinary interventions in an emergency or acute care context.

EarLy Exercise in blunt Chest wall Trauma: a feasibility trial (ELECT Trial)

BACKGROUND

The aim was to complete a feasibility study that would test the methods of the main trial, that will investigate whether early thoracic and shoulder girdle exercises reduce chronic pain in patients with blunt chest wall trauma, when compared with normal care.

METHODS

A single centre, parallel, feasibility randomised controlled trial was completed at a University Teaching Hospital in Wales between June and September 2019. Adult patients with blunt chest wall trauma, admitted to hospital for greater than 24 hours, with no concurrent, immediately life-threatening injuries, were included. The intervention was a simple physiotherapy programme comprising thoracic and shoulder girdle exercises. Feasibility outcome measures included: primary outcomes: (1) 80% or more of identified eligible patients were approached for potential recruitment to the trial (2) 30% or less of approached, eligible patients dissented to participate in the trial; secondary outcomes: (3) follow-up data for patient secondary outcomes can be collected for 80% or more of patients, (4) there should be no greater than 10% increase in serious adverse events in the intervention group compared with the control group.

RESULTS

A total of 19/19 (100%) patients were deemed eligible for the trial and were approached for participation, 5/19 (26%) eligible patients declined to participate in the trial, follow-up data were collected for n=10/14 (71%) patients and there were no serious adverse events reported in either group.

CONCLUSIONS

We have demonstrated that a fully powered randomised clinical trial of the EarLy Exercise in blunt Chest wall Trauma Trial is feasible.

TRIAL REGISTRATION NUMBER

ISRCTN16197429.

How does the implementation of a patient pathway-based intervention in the acute care of blunt thoracic injury impact on patient outcomes? A systematic review of the literature

BACKGROUND

Blunt thoracic injury is present in around 15% of all major trauma presentations. To ensure a standardised approach to the management of physical injury, patient pathway-based interventions have been established in many healthcare settings. It currently remains unclear how these complex interventions are implemented and evaluated in the literature. This systematic review aims to identify pathway effectiveness literature and implementation studies in relation to patient pathway-based interventions in blunt thoracic injury care.

METHODS

The databases Medline, Embase, Web of Science, CINAHL, WHO Clinical Trials Register and both the GreyLit & OpenGrey databases were searched without restrictions on date or study type. A search strategy was developed including keywords and MeSH terms relating to blunt thoracic injury, patient pathway-based interventions, evaluation and implementation. Due to heterogeneity of intervention pathways, meta-analysis was not possible; analysis was undertaken using an iterative narrative approach.

RESULTS

A total of 16 studies met the inclusion criteria and were included in analysis. Pathways were identified covering analgesic management, respiratory care, surgical decision making and reducing risk of complications. Studies evaluating pathways are generally limited by their observational and retrospective design, but results highlight the potential benefits of pathway driven care provision in blunt thoracic injury.

CONCLUSIONS

The results demonstrate the complexity of evaluating patient pathway-based interventions in blunt thoracic injury management. It is important that pathways undergo rigorous evaluation, refinement and validation to ensure quality and patient safety. Strong recommendations are precluded as the quality of the pathway evaluation studies are low.

Analysis of risk factors in thoracic trauma patients with a comparison of a modern trauma centre: a mono-centre study

Abstract

Objectives

Thoracic trauma (TT) is the third most common cause of death after abdominal injury and head trauma in polytrauma patients. Its management is still a very challenging task. The purpose of this study was to analyse the risk factors affecting the outcome in a high-volume trauma centre and the efficacy of a specialised trauma team in level 1 trauma centres.

Patients and methods

Between January 2003 and December 2012, data of all patients admitted to the accident and emergency (A&E) department were prospectively collected at the German Trauma Registry (GTR) and thereafter retrospectively analysed.

Patients with chest trauma, an Injury Severity Score (ISS) ≥ 18 and an Abbreviated Injury Scale (AIS) > 2 in more than one body region were included. Patients were divided into two groups: group I included patients presenting with thoracic trauma between January 2003 and December 2007. The results of this group were compared with the results of another group (group II) in a later 5-year period (Jan. 2008–Dec. 2012). Univariate and multivariate analyses were performed, and differences with p < 0.05 were considered statistically significant.

Results

There were 630 patients (56%) with thoracic trauma. A total of 540 patients (48%) had associated extrathoracic injuries. Group I consisted of 285 patients (197 male, mean age 46 years). Group II consisted of 345 patients (251 male, mean age 49 years). Overall 90-day mortality was 17% (n = 48) in group I vs. 9% (n = 31) in group II (p = 0.024). Complication rates were higher in group I (p = 0.019). Higher Injury Severity Scores (ISSs) and higher Abbreviated Injury Acale (AIS) scores in the thoracic region yielded a higher rate of mortality (p < 0.0001). Young patients (< 40 years) were frequently exposed to severe thoracic injury but showed lower mortality rates (p = 0.014). Patients with severe lung contusions (n = 94) (15%) had higher morbidity and mortality (p < 0.001). Twenty-three (8%) patients underwent emergency thoracotomy in group I vs. 14 patients (4%) in group II (p = 0.041). Organ replacement procedures were needed in 18% of patients in group I vs. 31% of patients in group II (p = 0.038).

Conclusions

The presence of severe lung contusion, a higher ISS and AIS_thoracic score and advanced age are independent risk factors that are directly related to a higher mortality rate. Management of blunt chest trauma with corrective chest tube insertion, optimal pain control and chest physiotherapy results in good outcomes in the majority of patients. Optimal management with better survival rates is achievable in specialised centres with multidisciplinary teamwork and the presence of thoracic surgical experience.

Physiotherapy management of patients with trunk trauma: A state-of-the-art review

BACKGROUND

Trauma injury remains a significant health risk for all on a global level. Patients with trunk trauma suffer blood loss, inflammation and hypoxia and are at risk of developing respiratory and musculoskeletal complications during their recovery. Physiotherapists are an integral part of the interprofessional team that manages patients who sustain trunk trauma.

OBJECTIVES

To describe the physiotherapy management of adult patients with trunk trauma, their quality of life, post-discharge rehabilitation service provision, and outcome measures used in the physiotherapy management.

METHOD

A non-systematic narrative review of published literature was performed.

RESULTS

Mobilisation, functional exercises, deep breathing exercises and active coughing are used to optimise patients' respiratory and musculoskeletal functioning. Some physiotherapists educate patients on the use of pain management strategies to reduce discomfort from rib fractures, surgical sites and intercostal drainage bottle tubing. Survivors of trunk trauma experience limitations in physical function up to two years. Little is known about post-discharge rehabilitation service provision to these patients after discharge. Few physiotherapists use outcome measures as part of their daily clinical practice.

CONCLUSION

Physiotherapy management of patients with blunt or penetrating trunk trauma during hospitalisation and after discharge is a field of clinical practice that is rich for high-quality research related to service provision, cost analysis and interventions used.

CLINICAL IMPLICATIONS

Physiotherapy clinicians and researchers can use the findings of this review as a guide to their management of adult patients recovering from trunk trauma.

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

Blunt chest wall trauma: an overview

Trauma affecting the chest wall, even in isolation, can carry a significant morbidity and mortality and thus appropriate management is vital. Consequences of chest wall trauma may include significant pain, altered chest wall mechanics, hypoventilation, infection and respiratory failure. In order to best determine the appropriate management, risk stratification tools have been developed to identify patients at highest risk of complications who would most benefit from more invasive management strategies. Early optimization of analgesia is vital both for patient experience and to reduce the risk of pulmonary complications. The analgesic options range from multimodal oral analgesia to invasive regional anaesthetic techniques such as thoracic epidurals, paravertebral catheters, intercostal nerve blocks and fascial plane blocks. Other important considerations include provision of appropriate oxygen therapy, ventilation support and physiotherapy. For a selected group of patients with the most significant injuries, surgical rib fixation may be appropriate if chest wall mechanics are sufficiently impaired.

Erector Spinae Block for Chest Trauma in Aeromedical Prehospital and Retrieval Medicine

Pain management for patients with chest trauma in aeromedical prehospital and retrieval medicine is important in order to maintain respiratory function. However, it can be challenging to achieve with opioids alone due to side effects including sedation, respiratory depression, and nausea.Reported are two trauma patients with uncontrolled pain despite multiple doses of opioids managed with a single-injection erector spinae plane block (ESB).The sono-anatomy and performance of the block, indications, and possible complications associated with the ESB are described.An ultrasound-guided ESB is useful for multimodal pain therapy following chest trauma in aeromedical retrieval medicine.

Physiotherapy management of patients with major chest trauma: Results from a global survey

Aim

Major chest trauma is associated with significant morbidity and mortality. Management of patients with major chest trauma includes pain relief, ventilatory management, surgical fixation and early rehabilitation to improve both short- and long-term outcomes. Physiotherapy is widely considered an integral component of the multidisciplinary trauma team and aims to improve respiratory status and reduce the sequelae associated with immobility and reduced physical function. Despite this there is scarce evidence describing or investigating physiotherapy interventions and how these practices vary worldwide. The aim of this study was to ascertain the current physiotherapy management of patients having sustained major chest trauma and to investigate how such practices varied internationally.

Methods

A purpose designed online survey was administered to a group of experienced physiotherapists who work in the field of trauma.

Results

Response rate was 51% ( n = 49) and respondents represented all five continents. Respondents reported focussing on active coughing ( n = 46, 96%, r = 0.5, p = 0.98), body positioning ( n = 43, 94%, r = 0.7, p = 0.41), deep breathing exercises ( n = 44, 94%, r = 0.8, p = 0.66) and early mobilisation ( n = 47, 98%, r = 1, p = 0.64). Ambulation in hospital was reported to be common ( n = 46, 98%, r = 0.2, p = 0.99) but rehabilitation to address longer term sequelae following hospital discharge was reported to be rare ( n = 4, 8%).

Conclusion

This survey has highlighted those practices used by physiotherapists worldwide which aim to address the complications associated with major chest trauma. Having established global practice, the study provides a platform for future research investigating the efficacy of such interventions in improving both short- and long-term outcomes for patients following major chest injury.

Rib fracture displacement worsens over time

PURPOSE

Rib fractures (RF) occur in 10% of trauma patients; associated with significant morbidity and mortality. Despite advancing technology of surgical stabilization of rib fractures (SSRF), treatment and indications remain controversial. Lack of displacement is often cited as a reason for non-operative management. The purpose was to examine RF patterns hypothesizing RF become more displaced over time.

METHODS

Retrospective review of all RF patients from 2016-2017 at our institution. Patients with initial chest CT (CT1) followed by repeat CT (CT2) within 84 days were included. Basic demographics were obtained. Primary outcomes included RF displacement in millimeters (mm) between CT1 and CT2 in three planes (AP = anterior/posterior, O = overlap/gap, and SI = superior/inferior). Displacement was calculated by subtracting CT1 fracture displacement from CT2 displacement for each rib. Given anatomic and clinical characteristics, ribs were grouped (1-2, 3-6, 7-10, 11-12), averaged, and analyzed for displacement. Secondary outcome included number of missed RF on CT1. Non-parametric sign test and paired t test were used for analysis. Significance was set at p < 0.002.

RESULTS

78 of 477 patients with RF on CT1 had CT2 during the study period: primarily male (76%) and age 55.8 ± 20.1 with blunt mechanism of injury (99%). Median Injury Severity Score was 21 (IQR, 13-27) with Chest Abbreviated Injury Score of 3 (IQR, 3-4). Median time between CT1 and CT2 was 6 days (IQR, 3-12). Missed RF rate for CT1 was 10.1% (p = 0.11). Average fracture displacement was significantly increased for all rib groupings except 11-12 in all planes (p < 0.002).

CONCLUSION

RF become more displaced over time. Pain regimens and SSRF considerations should be adjusted accordingly.

Case report: The use of three-dimensional biomodels for surgical planning of rib fixation

Background

Prosthetic titanium plates are frequently used in the stabilization of rib fractures and are typically contoured to the patient's anatomy at the time of implant in the operating room. Smith et al. [17] described the use of a 3D prototype biomodel of his patient's skeletal anatomy for preoperative customization of standard titanium plates for rib fractures. This process facilitated the preoperative planning and provided implants appropriate for a patient's unique anatomy. Further, the approach facilitated repair of complex fractures and may decrease operating time. Besides that, it provides idealized conditions for plate shaping and may facilitate implantation.

Methods

We performed rib fixation combined with 3D biomodels for surgical planning for the first time in Brazil, achieving reduced operating time with a good outcome for our patient.

Results

Surgical planning was conducted one day before the surgery using a 3D printer to make a patient-specific model. The printing time of the model was 16 h. The 3D biomodel was used for simulating the surgical procedure, pre-molding the titanium plates, and measuring the screw sizes that would be used in the procedure. All five fractures were fixed on the 3D biomodel and the total simulation time was 58 min. We used four pre-contoured titanium plates of 1.5 mm thickness and one straight 1.5 mm thickness titanium plate. We used the printed model to measure screw size, as we would do in the surgery. After planning, the material was processed and sterilized according to the hospital standards to be implanted in the patient the following day.

Conclusion

This is the second reported case of surgical stabilization of rib fractures using a 3D model. Both cases demonstrated the advantages of this approach. More studies are needed to validate the safety and benefits for the patient, as well as the impact on cost savings.

Diagnostic approach for myocardial contusion: a retrospective evaluation of patient data and review of the literature

Purpose

Myocardial contusion can be a life-threatening condition in patients who sustained blunt thoracic trauma. The diagnostic approach remains a subject of debate. The aim of this study was to determine the sensitivity and specificity of echocardiography, electrocardiography, troponins T and I (TnT and TnI), and creatine kinase muscle/brain (CK-MB) for identifying patients with a myocardial contusion following blunt thoracic trauma.

Methods

Sensitivity and specificity were first determined in a 10-year retrospective cohort study and second by a systematic literature review with meta-analysis.

Results

Of the 117 patients in the retrospective study, 44 (38%) were considered positive for myocardial contusion. Chest X-ray, chest CT scan, electrocardiograph, and echocardiography had poor sensitivity (< 15%) but good specificity (≥ 90%). Sensitivity to cardiac biomarkers measured at presentation ranged from 59% for TnT to 77% for hs-TnT, specificity ranged from 63% for CK-MB to 100% for TnT. The systematic literature review yielded 28 studies, with 14.5% out of 7242 patients reported as positive for myocardial contusion. The pooled sensitivity of electrocardiography, troponin I, and CK-MB was between 62 and 71%, versus only 45% for echocardiography and 38% for troponin T. The pooled specificity ranged from 63% for CK-MB to 85% for troponin T and 88% for echocardiography.

Conclusion

The best diagnostic approach for myocardial contusion is a combination of electrocardiography and measurement of cardiac biomarkers. If abnormalities are found, telemonitoring is necessary for the early detection of life-threatening arrhythmias. Chest X-ray and CT scan may show other thoracic injuries but provide no information on myocardial contusion.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01305-4) contains supplementary material, which is available to authorized users.

Feasibility of a Hybrid Web-Based and In-Person Self-management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma): A Pilot Randomized Controlled Trial

Objective 1) To assess the feasibility of research methods to test a self-management intervention aimed at preventing acute to chronic pain transition in patients with major lower extremity trauma (iPACT-E-Trauma) and 2) to evaluate its potential effects at three and six months postinjury. Design A pilot randomized controlled trial (RCT) with two parallel groups. Setting A supraregional level 1 trauma center. Methods Fifty-six adult patients were randomized. Participants received the intervention or an educational pamphlet. Several parameters were evaluated to determine the feasibility of the research methods. The potential efficacy of iPACT-E-Trauma was evaluated with measures of pain intensity and pain interference with activities. Results More than 80% of eligible patients agreed to participate, and an attrition rate of ≤18% was found. Less than 40% of screened patients were eligible, and obtaining baseline data took 48 hours postadmission on average. Mean scores of mild pain intensity and pain interference with daily activities (<4/10) on average were obtained in both groups at three and six months postinjury. Between 20% and 30% of participants reported moderate to high mean scores (≥4/10) on these outcomes at the two follow-up time measures. The experimental group perceived greater considerable improvement in pain (60% in the experimental group vs 46% in the control group) at three months postinjury. Low mean scores of pain catastrophizing (Pain Catastrophizing Scale score < 30) and anxiety and depression (Hospital Anxiety and Depression Scale scores ≤ 10) were obtained through the end of the study. Conclusions Some challenges that need to be addressed in a future RCT include the small proportion of screened patients who were eligible and the selection of appropriate tools to measure the development of chronic pain. Studies will need to be conducted with patients presenting more serious injuries and psychological vulnerability or using a stepped screening approach.

[Anesthesia, ventilation and pain treatment in thoracic trauma]

The management of anesthesia plays a central role in the treatment of thoracic trauma, both in the initial phase when safeguarding the difficult airway and in the intensive care unit. A rapid transfer to a trauma center should be considered in order to recognize and treat organ dysfunction in time. Development of atelectasis, pneumonia and acute lung failure are common pulmonary complications. Non-invasive ventilation combined with physiotherapy and respiratory training can help to minimize these pulmonary complications. If single lung ventilation is necessary as part of the operative patient care, a double-lumen tube, a bronchial blocker and the Univent®-Tubus (Fuji Systems Corporation, Tokyo, Japan) can be used. Special attention should be paid to the hypoxic pulmonary vasoconstriction that occurs in this maneuver. Pain therapy is ideally carried out patient-adapted with epidural anesthesia. In addition, intraoperatively inserted catheters in the sense of a continuous intercostal block or serratus plane block are good alternatives. The aim of these therapies should be early mobilization and transfer of the patient to rehabilitation.

Pain is vital in resuscitation in trauma

Implementation of the ATLS algorithm has remarkably improved the resuscitation of trauma patients and has significantly contributed to the systematic management of multi-trauma patients. However, pain remains the most prevalent complaint in trauma patients, and can induce severe complications, further deterioration of health, and death of the patient. Providing appropriate and timely pain management to these patients prompts early healing, reduces stress response, shortens hospital Length of Stay (LOS), diminishes chronic pain, and ultimately reduces morbidity and mortality. Pain has been proposed to be evaluated as the fifth vital sign and be recorded in the vital sign charts in order to emphasize the importance of pain on short- and long-term outcomes of the patients. However, although the quality of pain treatment seems to be improving we believe that pain has been underestimated in trauma. This article aims to provide evidence for the importance of pain in trauma, to support its management in the emergency setting and the acute phase of patients’ resuscitation, and to emphasize on the necessity to introduce the letter P (pain) in the ATLS alphabet.

A multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL Trial

OBJECTIVE

A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). The aim of this trial is to assess the feasibility and acceptability of a definitive impact trial investigating the clinical and cost-effectiveness of a new prognostic model for the management of patients with blunt chest wall trauma in the ED.

DESIGN

Stepped wedge feasibility trial.

SETTING

Four EDs in England and Wales.

PARTICIPANTS

Adult blunt chest wall trauma patients presenting to the ED with no concurrent, life-threatening injuries.

INTERVENTION

A prognostic model (the STUMBL score) to guide clinical decision-making.

OUTCOME MEASURES

Primary: participant recruitment rate and clinicians' use of the STUMBL score. Secondary: composite outcome measure (mortality, pulmonary complications, delayed upgrade in care, unplanned representations to the ED), physical and mental components of quality of life, clinician feedback and health economic data gathering methodology for healthcare resource utilisation.

RESULTS

Quantitative data were analysed using the intention-to-treat principle. 176 patients were recruited; recruitment targets were achieved at all sites. Clinicians used the model in 96% of intervention cases. All feasibility criteria were fully or partially met. After adjusting for predefined covariates, there were no statistically significant differences between the control and intervention periods. Qualitative analysis highlighted that STUMBL was well-received and clinicians would support a definitive trial. Collecting data on intervention costs, health-related quality of life and healthcare resource use was feasible.

DISCUSSION

We have demonstrated that a fully powered randomised clinical trial of the STUMBL score is feasible and desirable to clinicians. Minor methodological modifications will be made for the full trial.

TRIAL REGISTRATION NUMBER

ISRCTN95571506; Post-results.

Designing strategies to implement a blunt chest injury care bundle using the behaviour change wheel: a multi-site mixed methods study

Background

Blunt chest injury can lead to significant morbidity and mortality if not treated appropriately. A blunt chest injury care bundle was to be implemented at two sites to guide care.

Aim

To identify facilitators and barriers to the implementation of a blunt chest injury care bundle and design strategies tailored to promote future implementation.

Methods

1) A mixed-method survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the implementation of a blunt chest injury care bundle. This survey was distributed to 441 staff from 12 departments across two hospitals. Quantitative data were analysed using SPSS and qualitative using inductive content analysis.

2) The quantitative and qualitative results from the survey were integrated and mapped to each of the TDF domains.

3) The facilitators and barriers were evaluated using the Behaviour Change Wheel to extract specific intervention functions, policies, behaviour change techniques and implementation strategies. Each phase was assessed against the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects or safety and Equity (APEASE) criteria.

Results

One hundred ninety eight staff completed the survey. All departments surveyed were represented. Nine facilitators and six barriers were identified from eight domains of the TDF. Facilitators (TDF domains) were: understanding evidence-informed patient care and understanding risk factors (Knowledge); patient assessment skills and blunt chest injury management skills (Physical skills); identification with professional role (Professional role and identity); belief of consequences of care bundle (Belief about consequences); provision of training and protocol design (Environmental context and resources); and social supports (Social influences). Barriers were: not understanding the term ‘care bundle’ (Knowledge); lacking regional analgesia skills (Physical skills); not remembering to follow protocol (Memory, attention, and decision processes); negative emotions relating to new protocols (Emotions); equipment and protocol access (Environmental context and resources). Implementation strategies were videos, education sessions, visual prompt for electronic medical records and change champions.

Conclusions

Multiple facilitators and barriers were identified that may affect the implementation of a blunt chest injury care bundle. Implementation strategies developed through this process have been included in a plan for implementation in the emergency departments of two hospitals. Evaluation of the implementation is underway.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4177-z) contains supplementary material, which is available to authorized users.

Choice of Analgesia in Patients with Critical Skeletal Trauma

Introduction

The adequate management of thoracic trauma requires a systematic approach including pain control, respiratory therapy, and mobility achieved by surgical fixation. Failure to achieve pain control prolongs hospital stay. There are several options for achieving analgesia including epidural catheters, intravenous narcotics, intercostal, paravertebral or interpleural blocks, oral opioids, or simply a combination of the aforementioned interventions. In this study, we aim to compare the efficacy of thoracic epidural analgesia with systemic analgesia in patients with polytrauma.

Methods

This prospective study was conducted in the intensive care unit (ICU) of District Headquarters Hospital in Dera Ghazi Khan, Pakistan. Patients of age ≥18 years with skeletal trauma - rib fractures, limb fractures, and pelvic fractures - were included in the study. Group A patients were given epidural - bupivacaine and tramadol. Group B patients were given systemic analgesia with intravenous opioids. The severity of pain was assessed on the visual analogue scale (VAS) at time 0, 24 hours, and 48 hours. Data was entered and analysis was performed using Statistical Package for Social Sciences version 22.0.

Results

At 24 hours and 48 hours interval, group A showed a lower mean VAS score than group B (p = 0.74; p = 0.03). Group A required lesser mean doses of additional short-acting analgesics than group B (4.87 ± 1.06 vs. 6.77 ± 1.44; p < 0.0001). In Group A, 94% were discharged and the mortality rate was 6%; in group B, 86% were discharged and the mortality rate was 14% (p = 0.21).

Conclusion

Epidural analgesia provides better pain relief and requires fewer short-acting supplementing analgesics as compared to systemic analgesia in patients with multi-trauma.

Ageing population has changed the nature of major thoracic injury

Introduction

An increasing proportion of the major trauma population are older persons. The pattern of injury is different in this age group and serious chest injuries represent a significant subgroup, with implications for trauma system design. The aim of this study was to examine trends in thoracic injuries among major trauma patients in an inclusive trauma system.

Methods

This was a retrospective review of all adult cases of major trauma with thoracic injuries of Abbreviated Injury Scale score of 3 or more, using data from the Victorian State Trauma Registry from 2007 to 2016. Prevalence and pattern of thoracic injury was compared between patients with multitrauma and patients with isolated thoracic injury. Poisson regression was used to determine whether population-based incidence had changed over the study period.

Results

There were 8805 cases of hospitalised major trauma with serious thoracic injuries. Over a 10-year period, the population-adjusted incidence of thoracic injury increased by 8% per year (incidence rate ratio [IRR] 1.08, 95% CI 1.07 to 1.09). This trend was observed across all age groups and mechanisms of injury. The greatest increase in incidence of thoracic injuries, 14% per year, was observed in people aged 85 years and older (IRR 1.14, 95% CI 1.09 to 1.18).

Conclusions

Admissions for thoracic injuries in the major trauma population are increasing. Older patients are contributing to an increase in major thoracic trauma. This is likely to have important implications for trauma system design, as well as morbidity, mortality and use of healthcare resources.

Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults

OBJECTIVES

Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical rib fracture fixation as evidenced by systematic reviews.

DESIGN

A systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or unifocal non-flail rib fractures. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Science Citation Index were last searched 17 March 2017. Risk of bias was assessed using the Risk Of Bias In Systematic reviews (ROBIS) tool. The primary outcome was duration of mechanical ventilation.

RESULTS

Twelve systematic reviews were included, consisting of 3 unique randomised controlled trials and 19 non-randomised studies. Length of mechanical ventilation was shorter in the fixation group compared with the non-operative group in flail chest; pooled estimates ranged from -4.52 days, 95% CI (-5.54 to -3.5) to -7.5 days, 95% CI (-9.9 to -5.5). Pneumonia, length of hospital and intensive care unit stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of unifocal non-flail rib fracture population; due to limited evidence the benefits with surgery are uncertain.

CONCLUSIONS

Synthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence is required before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, unifocal non-flail rib fractures.

PROSPERO REGISTRATION NUMBER

CRD42016053494.