Background
- Common injuries and may be very significant
- Complications often due to inadequate analgesia/ventilation (atelectasis)
- Substantial ↑ risk in elderly and pre-existing lung disease
- Beware occult neighbouring injuries (e.g. vertebral # in blunt injury)
| Risk score | Probability mean ± SD |
|---|---|
| 0 - 10 | 13% ± 6 |
| 11 - 15 | 29% ± 8 |
| 16 - 20 | 52% ± 8 |
| 21 - 25 | 70% ± 6 |
| 26 - 30 | 80% ± 6 |
| 31+ | 88% ± 7 |
| From Battle C, Hutchings H, Lovett S, et al. (below) | |
Please use the calculator to gain advice on management.
Estimate complication risk and management advice.
Clinical
Causes
- Blunt e.g. MVAs, assault, falls
- Penetrating e.g. stabbing
- Coughing spells
- Non accidental injury
- Stress fractures in athletes
Symptoms
- Pleuritic pain
- Pain worse on torso/arm movement
- SoB
- Haemoptysis
Signs
- Localized pain and tenderness
- Hypoxia, respiratory distress
- ↑RR & use accessory muscles
- Palpable or visible deformity
- Paradoxical chest movements
- Tracheal deviation (very late)
- Surgical emphysema
- Percussion abnormalities
Complications
- Flail chest affects respiratory mechanics and increases work of breathing
- Haemothorax
- Pneumothorax
- Pulmonary Contusions evolve over the first 48 to 72 hours
- Superior vena caval obstruction
- Hepatosplenic injury - high degree of suspicion in lower rib fractures
- Cardiac contusions
- Mediastinal/Great vessel injury - particularly fractures of the scapula, first or second rib, or the sternum suggest a significant force of injury
- Oesophageal injury
- Diaphragmatic injury
- Atelectasis and Pneumonia which can be a consequence of inadequate analgesia and sputum clearance
Differential / Consider
- Abdominal Trauma
- Crying Child / NAI
- Domestic Violence / Elder Abuse
- Oesophagitis
- Fractures, Clavicle / sternal / vertebral etc
- Mechanical Back Pain
- Pneumothorax
- Pulmonary Embolism (PE)
- Upper Genitourinary Trauma
Investigations
- CXR
- Bedside US
- CT
- CT Angiogram
- Bone Scan
- MRI
- OGD or Bronchoscopy
Management
- The initial goal in the ED is stabilization so remember your ABCDs. This would include resuscitation, insertion of chest drains, transfusion of blood products etc
- Once stabilized complete your secondary survey to assess for other injuries
- Relief of pain is important to enable adequate ventilation
- Consider IV Parecoxib ± opiates
- Intercostal block, epidural anaesthesia, and systemic analgesics
- Respiratory care including incentive spirometry
- Utilize the chest injury score and Chest injury referral pathway to assess risk of complications and need for admission, anesthetic or cardiothoracic involvement
- Provide the patient with verbal and writtenChest/Rib Injury Advice
Links
References
- Battle C, Hutchings H, Lovett S, Bouamra O, Jones S, Sen A, Gagg J, Robinson D, Hartford-Beynon J, Williams J, Evans A. Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model. Crit Care. 2014 May 14;18(3):R98. doi: 10.1186/cc13873. PubMed PMID: 24887537; PubMed Central PMCID: PMC4095687
- IAEM Clinical Guideline: US-guided Erector Spinae Plane Block .... Mx Rib fractures in the ED. C D Vecchia, P Bullman, E Turcuman, C McDermot. 2023