Makindo Medical Notes

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina |Rib Fracture Score

Introduction

• 💥 Traumatic rib fractures are common after blunt chest trauma, with significant morbidity and mortality.
• 🫁 Respiratory complications (esp. pneumonia) occur in up to 31% of cases → early recognition and aggressive pain management are vital.
• 💊 Multimodal analgesia prevents hypoventilation and secretion retention, combining systemic + regional techniques.
• 🔧 In selected patients, surgical fixation improves outcomes by stabilising the chest wall.

Risk Factors

• 👴 More common in elderly due to osteoporosis and frailty.
• 🚗 High-energy trauma (RTAs, falls from height, crush injuries).
• 🦴 Underlying bone disease (osteoporosis, metastatic disease, myeloma).

Epidemiology

• 📊 Rib fractures in ~10% of all trauma patients.
• ~75% from blunt thoracic trauma, esp. RTAs.
• Associated with significant morbidity; severe cases → mortality up to 33%.

Pathophysiology

• 😣 Hypoventilation due to pain → atelectasis, impaired clearance, pneumonia.
• 🫀 Impaired gas exchange → pulmonary contusions, intrapulmonary shunting, hypoxia.
• 🫁 Altered mechanics → flail chest causes paradoxical movement, ↑ work of breathing, ↓ tidal volume.

Associated Injuries

• 1st/2nd rib → subclavian vessels, aorta, trachea, bronchus.
• Sternum → myocardium, great vessels, thoracic spine.
• Lower ribs → right = liver/kidney, left = spleen/kidney.

Flail Chest

• Multiple adjacent ribs fractured in ≥2 places → segment moves paradoxically.
• Paradoxical breathing worsens hypoxia, esp. with lung contusion.

Myocardial Contusion

• Often with sternal fractures.
• Features: chest pain, tachycardia, raised JVP, arrhythmias, troponin rise.
• ECG: arrhythmia, BBB, ST changes.
• Management: CCU/HDU monitoring, echocardiography if significant.

Investigations

• 🧪 Bloods: FBC, U&E, LFTs, Amylase, Lactate, ABG.
• ❤️ Cardiac markers: CK, Troponin.
• 🩻 Imaging: CXR, CT Traumogram (gold standard for extent & associated injuries).

Management & Rib Fracture Score (RFS)

• 🔑 ABC first → oxygen to maintain SpO₂ 94–98% (unless COPD).
• 💊 Pain control ladder:
  • Paracetamol 1 g PO/IV q6h
  • Ibuprofen 400 mg q8h (with PPI)
  • Lidocaine 5% plaster
  • Morphine PO/PRN or MST regularly
  • Adjuncts e.g. Gabapentin for neuropathic pain
• 🧾 RFS thresholds:
  • RFS ≤ 5 → ward care, oral/IV analgesia
  • RFS 6–10 → PCA, consider regional block, HDU
  • RFS ≥ 10 → ICU, thoracic epidural / paravertebral block
• 🏃 Early physiotherapy, incentive spirometry, mobilisation to reduce pneumonia risk.

Surgical Repair of Flail Chest

• Indicated in severe flail chest, respiratory failure, or prolonged ventilation.
• Fixation improves chest wall mechanics, ↓ pain, ↓ ICU stay, ↓ pneumonia risk.

Epidurals & Regional Analgesia

• Best for multiple/bilateral fractures, flail segments, severe pain.
• Contraindications:
  • Absolute: spinal injury, coagulopathy, local infection, patient refusal.
  • Relative: anticoagulation, spinal fractures, ↑ICP.
• Complications: Hypotension, motor block, urinary retention, opioid-related pruritus.

Complications & Prevention

• 🫁 Pneumonia – prevented by pain control, chest physio, mobilisation.
• 💔 Arrhythmias – screen for cardiac contusion in sternal fractures.
• 🩸 VTE – prophylaxis with LMWH unless contraindicated.
• 🧠 Delirium (elderly) – optimise pain, sleep, minimise opioids where possible.

🌟 Clinical Pearl: Pain control = the single most important intervention. Poor analgesia → hypoventilation → pneumonia → ICU admission.

References

• British Journal of Anaesthesia Education: Rib fracture management
• NICE: Major trauma: service delivery