Rib fracture: Difference between revisions
Neil.m.young (talk | contribs) No edit summary |
Neil.m.young (talk | contribs) No edit summary |
||
| Line 1: | Line 1: | ||
=Background= | ==Background== | ||
[[File:multipleribfractures.png|thumbnail|Multiple Right sided rib fractures]] | [[File:multipleribfractures.png|thumbnail|Multiple Right sided rib fractures]] | ||
*Diagnostic goal: detect commonly associated conditions: hemopneumothorax, pulmonary contusion, intra-abdominal injury, major vascular injury | *Diagnostic goal: detect commonly associated conditions: hemopneumothorax, pulmonary contusion, intra-abdominal injury, major vascular injury | ||
| Line 6: | Line 6: | ||
*Elderly: double the mortality of younger patients | *Elderly: double the mortality of younger patients | ||
= | ==Clinical Features== | ||
* | *Rib pain | ||
* | *Assess for flail chest | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Thoracic trauma DDX}} | {{Thoracic trauma DDX}} | ||
==Diagnosis== | |||
*CXR (Consider xray rib views) | |||
**May only pick up 24% of fractures<ref>Rainer TH, Griffith JF, Lam E, et al. Comparison of thoracic ultrasound, clinical acumen, and radiography in patients with minor chest injury. J Trauma 2004:56;1211–13.</ref> | |||
**9th, 10th, 11th rib fractures associated with intra-abdominal injury | |||
*CT thorax without contrast for more definitive diagnosis | |||
**Sensitivity 0.63 and specificity 0.97<ref>Schulze C, Hoppe H, Schweitzer W, et al. Rib fractures at postmortem computed tomography (PMCT) validated against the autopsy. Forensic Sci Int. 2013; 233(1-3):90-98.</ref> | |||
==Management== | ==Management== | ||
*Dilaudid PCA upon decision to admit<ref>Dept of Surg Edu at Orlando Regional Medical Center. Multi-modality pain control for rib fractures. Surgical Critical Care. 11/30/2010. http://www.surgicalcriticalcare.net/Guidelines/rib%20fracture%202010.pdf</ref> | ===Admission=== | ||
*Consider [[Dilaudid]] PCA upon decision to admit<ref>Dept of Surg Edu at Orlando Regional Medical Center. Multi-modality pain control for rib fractures. Surgical Critical Care. 11/30/2010. http://www.surgicalcriticalcare.net/Guidelines/rib%20fracture%202010.pdf</ref> | |||
*Incentive spirometry | *Incentive spirometry | ||
*EzPAP® positive airway pressure system | *EzPAP® positive airway pressure system | ||
| Line 25: | Line 32: | ||
*Consider addition of: | *Consider addition of: | ||
**Continuous epidural bupivacaine infusion if failure of PCA/NSAIDs | **Continuous epidural bupivacaine infusion if failure of PCA/NSAIDs | ||
**Paracostal infusions of bupivacaine via elastomeric pump (ex. On-Q or C-Bloc) | |||
**Diazepam 10 mg IV/PO q4-6 hrs if respiratory rate adequate | **Diazepam 10 mg IV/PO q4-6 hrs if respiratory rate adequate | ||
===Discharge=== | |||
*Teach how to splint and cough | |||
*Be liberal with pain medicine | |||
*Encourage incentive spirometer or tell to blow up balloons | |||
*Discourage rib belts or straps | |||
=Disposition= | ==Disposition== | ||
*Strongly consider admission for more than one rib fracture in elderly patient or patient with preexisting pulmonary disease | *Strongly consider admission for more than one rib fracture in elderly patient or patient with preexisting pulmonary disease | ||
**Difficult for these patients to cough / clear secretions | **Difficult for these patients to cough / clear secretions | ||
==See Also== | ==See Also== | ||
Revision as of 16:17, 29 September 2015
Background
- Diagnostic goal: detect commonly associated conditions: hemopneumothorax, pulmonary contusion, intra-abdominal injury, major vascular injury
- Pediatrics: <2 years old with >2 rib fractures = 50% mortality
- Ribs more flexible in children, so fractures require extreme force
- Elderly: double the mortality of younger patients
Clinical Features
- Rib pain
- Assess for flail chest
Differential Diagnosis
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Diagnosis
- CXR (Consider xray rib views)
- May only pick up 24% of fractures[1]
- 9th, 10th, 11th rib fractures associated with intra-abdominal injury
- CT thorax without contrast for more definitive diagnosis
- Sensitivity 0.63 and specificity 0.97[2]
Management
Admission
- Consider Dilaudid PCA upon decision to admit[3]
- Incentive spirometry
- EzPAP® positive airway pressure system
- Early NSAIDs for multiple rib fractures to reduce pna
- Ibuprofen 800 mg IV q6hrs
- OR ketorolac 15-30 mg IV q6 hrs[4]
- Limit IV NSAIDs to maximum of 5 days
- Transition to PO narcotics and NSAIDs whenever possible
- Consider addition of:
- Continuous epidural bupivacaine infusion if failure of PCA/NSAIDs
- Paracostal infusions of bupivacaine via elastomeric pump (ex. On-Q or C-Bloc)
- Diazepam 10 mg IV/PO q4-6 hrs if respiratory rate adequate
Discharge
- Teach how to splint and cough
- Be liberal with pain medicine
- Encourage incentive spirometer or tell to blow up balloons
- Discourage rib belts or straps
Disposition
- Strongly consider admission for more than one rib fracture in elderly patient or patient with preexisting pulmonary disease
- Difficult for these patients to cough / clear secretions
See Also
References
- ↑ Rainer TH, Griffith JF, Lam E, et al. Comparison of thoracic ultrasound, clinical acumen, and radiography in patients with minor chest injury. J Trauma 2004:56;1211–13.
- ↑ Schulze C, Hoppe H, Schweitzer W, et al. Rib fractures at postmortem computed tomography (PMCT) validated against the autopsy. Forensic Sci Int. 2013; 233(1-3):90-98.
- ↑ Dept of Surg Edu at Orlando Regional Medical Center. Multi-modality pain control for rib fractures. Surgical Critical Care. 11/30/2010. http://www.surgicalcriticalcare.net/Guidelines/rib%20fracture%202010.pdf
- ↑ Yang Y et al. Use of ketorolac is associated with decreased pneumonia following rib fractures. Am J Surg. 2014 Apr;207(4):566-72. doi: 10.1016/j.amjsurg.2013.05.011. Epub 2013 Oct 7.