Blunt chest wall trauma: an overview

Efficacy and safety of the serratus anterior plane block (SAP block) for pain management in patients with multiple rib fractures in the emergency department: a retrospective study

PURPOSE

Chest trauma is a severe and frequent cause of admission to the emergency department (ED). The serratus anterior plane (SAP) block seems to be an effective method of pain management; however, data on efficacy and safety of a single SAP block performed in the ED by emergency physicians (EP) are limited. This study aimed to compare SAP block performed by the EP in the ED plus standard therapy to standard therapy alone in terms of pain severity at 0-3-6-12-18 and 24 h, total opioid consumption (milligrams of morphine equivalents, MME), respiratory function (SpO2/FiO2 ratio), and adverse events (i.e. pneumothorax, infections in the site of injection, or Local Anaesthetic Systemic Toxicity syndrome due to SAP block) in the first 24 h.

METHODS

This retrospective, monocentric study included adult patients admitted to the Sub-intensive Care Unit (SICU) of the ED with multiple rib fractures between 01/2022 and 03/2023.

RESULTS

156 patients (65.4% male; median age 62 years; median injury severity score 16; median thoracic trauma severity score 8) were included. 75 (48.2%) underwent SAP block. Patients undergoing SAP block showed significantly less pain 3-6-18 h after a single block, required less MME (0 [0-20] vs. 20 [0-40], p < 0.001), showed higher SpO2/FiO2 ratio, and no adverse events were reported.

CONCLUSION

The SAP block, in combination with standard therapy, appeared to be more effective in providing pain relief than standard therapy alone in patients admitted to the SICU for traumatic rib fractures.

High-flow nasal cannula oxygen therapy for mild-moderate acute respiratory failure in patients with blunt chest trauma: An exploratory descriptive study

OBJECTIVE

The use of high-flow nasal cannula (HFNC) oxygen therapy is gaining popularity for the treatment of acute respiratory failure (ARF). However, limited evidence exists regarding the effectiveness of HFNC for hypoxemic ARF in patients with blunt chest trauma (BCT).

METHODS

This retrospective analysis focused on BCT patients with mild-moderate hypoxemic ARF who were treated with either HFNC or non-invasive ventilation (NIV) in the emergency medicine department from January 2021 to December 2022. The primary endpoint was treatment failure, defined as either invasive ventilation, or a switch to the other study treatment (NIV for patients in the NFNC group, and vice-versa).

RESULTS

A total of 157 patients with BCT (72 in the HFNC group and 85 in the NIV group) were included in this study. The treatment failure rate in the HFNC group was 11.1% and 16.5% in the NIV group - risk difference of 5.36% (95% CI, -5.94-16.10%; P = 0.366). The most common cause of failure in the HFNC group was aggravation of respiratory distress. While in the NIV group, the most common reason for failure was treatment intolerance. Treatment intolerance in the HFNC group was significantly lower than that in the NIV group (1.4% vs 9.4%, 95% CI 0.40-16.18; P = 0.039). Univariate logistic regression analysis showed that chronic respiratory disease, abbreviated injury scale score (chest) (≥3), Acute Physiology and Chronic Health Evaluation II score (≥15), partial arterial oxygen tension /fraction of inspired oxygen (≤200) at 1 h of treatment and respiratory rate (≥32 /min) at 1 h of treatment were risk factors associated with HFNC failure.

CONCLUSION

In BCT patients with mild-moderate hypoxemic ARF, the usage of HFNC did not lead to higher rate of treatment failure when compared to NIV. HFNC was found to offer better comfort and tolerance than NIV, suggesting it may be a promising new respiratory support therapy for BCT patients with mild-moderate ARF.

The lived experiences of healthcare professionals working in pre-hospital emergency services in Jordan: A qualitative exploratory study

INTRODUCTION

Globally, injuries account for 9% of all deaths, with road accidents contributing to approximately a quarter of these fatalities. A major concern is the inadequacy of pre-hospital care (emergency medical services provided before arrival at a hospital) and delays in transportation to medical facilities, identified as leading causes of preventable injury-related deaths. This study explores the experiences of emergency health professionals (EHPs) in peri-hospital services (emergency medical services provided immediately upon arrival and within the hospital setting).

METHODS

A qualitative exploratory design, underpinned by Van Manen's (1990) descriptive phenomenological principles, was used. Thirty EHPs from five central and southern Jordanian emergency departments were purposefully sampled, including physicians, nurses, and paramedics from both emergency departments and pre-hospital services.

RESULTS

Two primary themes emerged: (1) In Search of Clarity: The Unsettled Journey of Pre-hospital Emergency Care Providers; (2) Frustrations on the Frontline: Role Ambiguity and Emotional Exhaustion in Trauma Care, with EHPs reporting fluid and unclear roles, physical and verbal abuse, and limited authority in critical interventions.

CONCLUSION

The study highlights several service lapses in peri-hospital care that negatively impact healthcare professionals, posing risks to patient safety. These findings urge decision-makers to devise actionable strategies to rectify these deficiencies, enhancing care quality and thereby decreasing injury-induced mortality and morbidity.

Scoping review of the literature to ascertain how the STUMBL Score clinical prediction model is used to manage patients with blunt chest wall trauma in emergency care

INTRODUCTION

The STUMBL Score clinical prediction model was originally developed and externally validated to support clinical decision-making of patients with blunt chest wall trauma in the Emergency Department. The aim of this scoping review was to understand the extent and type of evidence in relation to the STUMBL Score clinical prediction model as a component of the management of patients with blunt chest wall trauma managed in the Emergency Care setting.

METHODS

A systematic search was conducted across databases, including Medline, Embase and the Cochrane Central Register of Controlled Trials from Jan 2014 to Feb 2023. In addition, a search of the grey literature was undertaken along with citation searching of relevant studies. Published and non-published sources of all research designs were included. Data extracted included specific details about the participants, concept, context, study methods and key findings relevant to the review question. Data extraction followed the JBI guidance and results presented in tabular format accompanied with a narrative summary.

RESULTS

A total of 44 sources originating from eight countries were identified, 28 were published and 16 grey literature. Sources were grouped into four separate categories: 1) external validation studies, 2) guidance documents, 3) practice reviews and educational resources 3) research studies and quality improvement projects, 4) grey literature unpublished resources. This body of evidence describes the clinical utility of the STUMBL Score and has identify how the score is being implemented and used differently in different settings including analgesic selection and participant eligibility for including in chest wall injury research studies.

DISCUSSION

This review demonstrates how the STUMBL Score has evolved from solely predicting risk of respiratory complications to a measure which supports clinical decision making for the use of complex analgesic modes and as a guide for eligibility in chest wall injury trauma research studies. Despite external validation of the STUMBL Score, there is a need for further calibration and evaluation, particularly relating to these repurposed functions of the score. Overall, the clinical benefit of the score remains clear and its wide usage demonstrates the impact it has on clinical care, patient experience and clinician decision making.

Blunt chest wall trauma: Rib fractures and associated injuries

ABSTRACT

Blunt injuries to the chest wall, specifically those related to rib fractures, need to be promptly identified and effectively managed to reduce patient morbidity and mortality. Furthermore, judicious use of multimodal pain management and early identification of patients who will benefit from the surgical stabilization of rib fractures are paramount to optimal outcomes.

Cryoneurolysis of Intercostal Nerve for Rib Trauma and Intercostal Neuralgia in the Emergency Department: A Multidisciplinary Approach

BACKGROUND

Management of pain from traumatic rib injury is very challenging. Both acute and chronic pain caused by rib injury can cause significant morbidity (pain-induced hypoventilation, pneumonia, respiratory failure) and functional hindrance. Traditional pain management strategies in the emergency department (ED) that target acute traumatic rib pain are limited by the side effects of medications or the temporary half-life of anesthetics used for a nerve block. Both treatment modalities fall short of addressing subsequent chronic sequelae.

CASE REPORT

We present the first-time use of cryoneurolysis on an ED patient for the treatment of 10/10 severe traumatic intercostal neuralgia that resulted in the patient being discharged home pain free. The patient initially underwent a multilevel left-sided T5-T7 intercostal nerve block, followed by ultrasound-guided percutaneous cryoneurolysis of those intercostal nerves using two cycles of 2 min of cooling to a temperature of -70°C (nitrous oxide), with 30 s of thawing in between. The patient experienced 100% pain relief immediately post procedure that was sustained. He remained completely symptom free more than 6 months after the bedside procedure and returned to sports without restrictions. Why Should an Emergency Physician Be Aware of This? This case highlights the benefits of cross-departmental collaboration between the ED, Anesthesia, and Pain Management. We hope this model of multidisciplinary pain modulation can be replicated for other patients with similar pain and can herald a new paradigm of pain management in the ED.

Risk of Pneumonia in Pediatric Patients Following Minor Chest Trauma: A Population-Based Retrospective Cohort Study

This study investigated the association between minor chest trauma and the risk of pneumonia among pediatric patients in a Taiwanese health care setting. For this retrospective population-based cohort study, the Longitudinal Health Insurance Database was used to analyze the data of patients with a minor chest injury between 2010 and 2012. Data were analyzed through a multivariate analysis with a multiple Cox regression model. Patients were divided into a chest trauma group (n = 6592) and a non-chest trauma group (n = 882,623). An increased risk of pneumonia was observed in the chest trauma group (hazard ratio = 1.23; 95% confidence interval = 1.02–1.49) compared to the non-chest trauma group. In conclusion, this population-based cohort study demonstrated that pediatric patients with minor chest trauma are at an increased risk of pneumonia. The short-term adverse effects of pneumonia could be severe when a patient suffers from mild chest trauma.

The Treatment of Rib Fractures : A Single-Center Comparison

BACKGROUND

Rib fractures are a major problem characterized by pain, increased length of stay, and respiratory complications. Treatments include fixation, management with opiates, paraspinous local anesthetic pumps, and intercostal nerve blocks. The aim of this study was to evaluate the use of treatment options and compare clinically relevant outcomes.

METHODS

Patients admitted to a Level 1 trauma center with multiple rib fractures between 2015 and 2019 were screened. We included all participants treated with surgical fixation and/or intercostal nerve block or local anesthetic pump. Patients were case-matched 1:2 by Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) Chest and Head, age, and number of rib fractures. Outcomes assessed were hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, pneumonia, and tracheostomy rates.

RESULTS

We identified 25 patients who received rib fixation and intercostal analgesia. Of these, 14 cases were treated with liposomal bupivaicaine nerve block and 11 by paraspinous catheter block. Fifty control cases treated with opiates were identified. All patients survived to discharge. Cases and controls were approximately equivalent in age, ISS, number of fractured ribs, chest AIS, and head AIS. Rib-plated patients had a lower rate of pneumonia (OR 0.2029, 95% CI 0.0242, 0.09718), decreased average ICU LOS (10.62 vs 6.64, P = .018), and decreased average ventilator days (5.44 vs 1.68, P = .003).

DISCUSSION

Findings suggest more aggressive treatment of rib fractures may decrease ICU LOS, ventilator days, and pneumonia in patients with multiple rib fractures. These findings are in line with current literature; however, more research is needed in this area.