RESUMO
BACKGROUND: One of the worst types of severe chest injuries seen by clinicians is flail chest. This study aims to measure the overall mortality rate among flail chest patients and then to correlate mortality with several demographic, pathologic, and management factors. METHODOLOGY: A retrospective observational study tracked a total of 376 flail chest patients admitted to the emergency intensive care unit (EICU) and surgical intensive care unit (SICU) at Zagazig University over 120 months. The main outcome measurement was overall mortality. The secondary outcomes were the association of age and sex, concomitant head injury, lung and cardiac contusions, the onset of mechanical ventilation (MV) and chest tubes insertion, the length of mechanical ventilation and ICU stay in days, injury severity score (ISS), associated surgeries, pneumonia, sepsis, the implication of standard fluid therapy and steroid therapy, and the systemic and regional analgesia, with the overall mortality rates. RESULTS: The mortality rate was 19.9% overall. The shorter onset of MV and chest tube insertion, and the longer ICU, and hospital length of stay were noted in the mortality group compared with the survived group (P-value less than 0.05). Concomitant head injuries, associated surgeries, pneumonia, pneumothorax, sepsis, lung and myocardial contusion, standard fluid therapy, and steroid therapy were significantly correlated with mortality (P-value less than 0.05). MV had no statistically significant effect on mortality. Regional analgesia (58.8%) had a significantly higher survival rate than intravenous fentanyl infusion (41.2%). In multivariate analysis, sepsis, concomitant head injury, and high ISS were independent predictors for mortality [OR (95% CI) = 568.98 (19.49-16613.52), 6.86 (2.86-16.49), and 1.19 (1.09-1.30), respectively]. CONCLUSION: The current report recorded mortality of 19.9% between flail chest injury patients. Sepsis, concomitant head injury, and higher ISS are the independent risk factors for mortality when associated with flail chest injury. Considering restricted fluid management strategy and regional analgesia may help better outcome for flail chest injury patients.
Assuntos
Traumatismos Craniocerebrais , Tórax Fundido , Pneumonia , Sepse , Traumatismos Torácicos , Humanos , Tórax Fundido/epidemiologia , Tórax Fundido/terapia , Tórax Fundido/complicações , Países em Desenvolvimento , Centros de Atenção Terciária , Traumatismos Torácicos/complicações , Traumatismos Torácicos/patologia , Traumatismos Torácicos/cirurgia , Morbidade , Sepse/complicações , Esteroides , Estudos Retrospectivos , Tempo de InternaçãoRESUMO
A flail chest is one of the possible medical conditions suffered by individuals who were injured in traffic accidents, caused by multiple fractures of the ribs and sternum. Which often results in paradoxical chest movements. The consequence may be respiratory failure and need for long-term mechanical ventilation. Such treatment require Intensive Care Unit and may be associated with the possibility of numerous complications.Modified Nuss procedure was performed in 79-year-old man, a victim of a car crash to obtain stabilization of the flail chest. After compensation of paradoxical movements on the third day it was possible to end mechanical ventilation. A quick procedure dedicated to the congenital deformation of the chest made it possible to avoid long, expensive intensive therapy with possible respiratory complications.The NUSS procedure enables the effective and safe treatment of a flail chest in a selected group of patients.
Assuntos
Tórax Fundido , Insuficiência Respiratória , Fraturas das Costelas , Masculino , Humanos , Idoso , Tórax Fundido/terapia , Fraturas das Costelas/cirurgia , Costelas , EsternoRESUMO
BACKGROUND: Pulmonary contusion has been considered a contraindication to surgical stabilization of rib fractures (SSRFs). This study aimed to evaluate the association between pulmonary contusion severity and outcomes after SSRF. We hypothesized that outcomes would be worse in patients who undergo SSRF compared with nonoperative management, in presence of varying severity of pulmonary contusions. METHODS: This retrospective cohort study included adults with three or more displaced rib fractures or flail segment. Patients were divided into those who underwent SSRF versus those managed nonoperatively. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score. Outcomes (pneumonia, tracheostomy, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, mortality) were retrieved from patients' medical records. Comparisons were made using Fisher's exact and Kruskal-Wallis tests, and correction for potential confounding was done with regression analyses. RESULTS: A total of 221 patients were included; SSRF was performed in 148 (67%). Demographics and chest injury patterns were similar in SSRF and nonoperatively managed patients. Surgical stabilization of rib fracture patients had less frequent head and abdominal/pelvic injuries ( p = 0.017 and p = 0.003). Higher BPC18 score was associated with worse outcomes in both groups. When adjusted for ISS, the ICU stay was shorter (adjusted ß , -2.511 [95% confidence interval, -4.87 to -0.16]) in patients with mild contusions who underwent SSRF versus nonoperative patients. In patients with moderate contusions, those who underwent SSRF had fewer ventilator days (adjusted ß , -5.19 [95% confidence interval, -10.2 to -0.17]). For severe pulmonary contusions, outcomes did not differ between SSRF and nonoperative management. CONCLUSION: In patients with severe rib fracture patterns, higher BPC18 score is associated with worse respiratory outcomes and longer ICU and hospital admission duration. The presence of pulmonary contusions is not associated with worse SSRF outcomes, and SSRF is associated with better outcomes for patients with mild to moderate pulmonary contusions. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
Assuntos
Contusões , Tórax Fundido , Lesão Pulmonar , Fraturas das Costelas , Adulto , Humanos , Fraturas das Costelas/complicações , Fraturas das Costelas/cirurgia , Estudos Retrospectivos , Tórax Fundido/terapia , Tórax Fundido/cirurgia , Lesão Pulmonar/complicações , Contusões/complicações , Contusões/terapia , Costelas , Tempo de InternaçãoRESUMO
OBJECTIVES: Blunt chest trauma after mechanical resuscitation manoeuvres appears to have a significant impact on the often complicated course. Due to a lack of data in the literature, the purpose of this study was to investigate the feasibility and immediate outcome of chest wall stabilization for flail chest in this vulnerable patient population. METHODS: We retrospectively reviewed the medical records of patients after cardiopulmonary resuscitation between January 2014 and December 2018 who were diagnosed with flail chest. We attempted to compare patients after surgery with those after conservative treatment. RESULTS: Of a total of 56 patients with blunt chest trauma after mechanical resuscitation and after coronary angiography, 25 were diagnosed with flail chest. After the exclusion of 2 patients because of an initial decision to palliate, 13 patients after surgical stabilization could be compared with 10 patients after conservative therapy. Although there was no significant difference in the total duration of ventilatory support, there was a significant advantage when the time after stabilization to extubation was compared with the duration of ventilation in the conservative group. The presence of pulmonary contusion, poor Glasgow Coma Scale score or the development of pneumonia negatively affected the outcome, but additional sternal fracture did not. CONCLUSIONS: Surgical stabilization for chest wall instability is well tolerated even by this vulnerable patient population. Our results should be used for further randomized controlled approaches. It is necessary to evaluate the situation with all parameters in an interdisciplinary manner and to decide on a possible surgical therapy at an early stage if possible.
Assuntos
Reanimação Cardiopulmonar , Tórax Fundido , Fraturas das Costelas , Traumatismos Torácicos , Ferimentos não Penetrantes , Reanimação Cardiopulmonar/efeitos adversos , Tórax Fundido/diagnóstico por imagem , Tórax Fundido/etiologia , Tórax Fundido/terapia , Fixação Interna de Fraturas/métodos , Humanos , Respiração Artificial/efeitos adversos , Estudos Retrospectivos , Fraturas das Costelas/diagnóstico por imagem , Fraturas das Costelas/etiologia , Fraturas das Costelas/cirurgia , Traumatismos Torácicos/cirurgia , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgiaRESUMO
BACKGROUND: Rib fractures serve as both a marker of injury severity and a guide for clinical decision making for trauma patients. Although recent studies have suggested that rib fractures are dynamic, the degree of progressive offset remains unknown. The purpose of this study was to further characterize the change that takes place in the acute trauma setting. METHODS: A 4-year (2016-2019) retrospective assessment of adult trauma patients with rib fracture(s) admitted to a level I trauma center was performed. Initial and follow-up computed tomography scans were analyzed to determine the magnitude of offset. Relevant clinical course variables were examined, and location of chest wall instability was examined using the difference of interquartile range of median change. Statistical Product and Services Solutions (Version 25, IBM Corp. Armonk, NY) was then used to generate a neural network-multilayer perceptron that highlighted independent variable importance. RESULTS: Fifty-three patients met the inclusion criteria for severe injury. Clinical course variables that either trended or significantly predicted the occurrence of progressive offset were Abbreviated Injury Scale Thoracic Scores (3.1 ± 0.4 no progression vs. 3.4 ± 0.6 yes progression; p = 0.121), flail segment (14% no progression vs. 43% yes progression; p = 0.053), and number of ribs fractured (4 [2-8] no progression vs. 7 [5-9] yes progression; p = 0.023). The location of progressive offset largely corresponded to the posterolateral region as demonstrated by the differences of interquartile range of median change. The neural network demonstrated that ribs 4 to 6 (normalized importance [NI], 100%), the posterolateral region (NI, 87.9%), and multiple fractures per rib (NI, 66.6%) were valuable in predicting whether progressive offset occurred (receiver operating characteristic curve - area under the curve = 0.869). CONCLUSION: Rib fractures are not stable, particularly for those patients with multiple fractures in the mid-to-upper ribs localized to the posterolateral region. These findings may identify both trauma patients with worse outcomes and help develop better management strategies for rib fractures. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.
Assuntos
Tórax Fundido , Pneumopatias , Redes Neurais de Computação , Fraturas das Costelas , Traumatismos Torácicos/terapia , Tomada de Decisão Clínica/métodos , Progressão da Doença , Feminino , Tórax Fundido/etiologia , Tórax Fundido/terapia , Humanos , Escala de Gravidade do Ferimento , Pneumopatias/etiologia , Pneumopatias/terapia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/métodos , Assistência ao Paciente/métodos , Assistência ao Paciente/normas , Melhoria de Qualidade , Estudos Retrospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/diagnóstico , Fraturas das Costelas/terapia , Tomografia Computadorizada por Raios X/métodos , Centros de Traumatologia/estatística & dados numéricosRESUMO
BACKGROUND: Randomized controlled trials have demonstrated that surgical stabilization of rib fractures (SSRF) in selected trauma patients is associated with potential benefits. This study evaluates the real-world outcomes of SSRF since its implementation at Westmead Hospital, Australia. We hypothesize these outcomes to be similar to that reported by best-evidence in the literature. MATERIALS AND METHODS: A retrospective analysis of data on all consecutive SSRF performed between January 2013 to December 2018 was completed. RESULTS: Sixty-three patients (54 male; average age 55.9 ± 14.1 y) with median ISS 24 (IQR 17;30) underwent SSRF. Thirty-seven patients were admitted to Intensive Care Unit (ICU), with median ICU length of stay (LOS) 10.0 (5.0-17.0) d. Median hospital LOS was 15.5 (10.0-24.8) d. Fifty-five (87.3%) patients did not have any surgery-specific complications. The highest observed surgical morbidity was wound infection (n = 4, 4.7%). There was one mortality after rib fixation that was not related to surgery. SSRF within 3 d of hospital presentation in ventilated patients with flail chest was associated with significantly reduced median ICU LOS (3.0 [2.0;4.0] versus 10.0 [9.3;13.0] d; P = 0.03). Early (2013-2015) versus late (2015-2018) phase SSRF implementation demonstrated no significant difference in outcome variables. CONCLUSION: Experience with SSRF demonstrates early outcomes similar to best-evidence in the existing literature. As a quality assurance tool, ongoing evaluation of real-world data is needed to ensure that outcomes remain consistent with benchmarks available from best-evidence.
Assuntos
Tórax Fundido/terapia , Fixação Interna de Fraturas/métodos , Respiração Artificial/estatística & dados numéricos , Fraturas das Costelas/cirurgia , Tempo para o Tratamento/estatística & dados numéricos , Adulto , Idoso , Placas Ósseas , Feminino , Tórax Fundido/etiologia , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , New South Wales , Estudos Prospectivos , Estudos Retrospectivos , Fraturas das Costelas/complicações , Resultado do TratamentoRESUMO
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.
Assuntos
Lesão Pulmonar , Manejo da Dor , Traumatismos Torácicos , Parede Torácica/lesões , Ferimentos não Penetrantes , Tórax Fundido/terapia , Hemotórax/terapia , Humanos , Lesão Pulmonar/terapia , Pneumotórax/terapia , Fraturas das Costelas/terapia , Traumatismos Torácicos/terapia , Ferimentos não Penetrantes/terapiaRESUMO
Flail chest is defined by fracture of 3 or more adjacent ribs, at 2 or more sites, with paradoxical movement of the affected chest. It occurs in 2 to 4 % of blunt chest trauma, with a mortality of 10 to 15 %. Treatment is conservative, using analgesia and positive pressure ventilation, or surgical osteosynthesis of rib fractures. We present the case of a 9-year-old girl with blunt chest trauma and flail chest. Computed tomography showed rib fractures from 2nd to 7th left ribs, in middle and anterior arches. Due to inadequate pain management, it was placed in mechanical ventilation. After 72 hours the surgical resolution was decided, osteosynthesis of the 3rd to 7th ribs was performed. The patient evolved favorably. The surgical management allowed reducing days of mechanical ventilation and days of hospitalization.
El tórax inestable se define por fractura de 3 o más costillas adyacentes, en 2 o más sitios, con movimiento paradojal del tórax afectado. Se presenta en el 2-4 % de los traumas de tórax contusos, con una mortalidad del 10-15 %. El tratamiento se realiza de forma conservadora, mediante analgesia y el uso de ventilación con presión positiva o, quirúrgicamente, mediante osteosíntesis de las fracturas costales. Se presenta el caso de una niña de 9 años con diagnóstico de traumatismo cerrado de tórax y tórax inestable. En la tomografía computada, se evidenciaron fracturas costales de 2da a 7ma izquierdas, arcos medios y anteriores. Por inadecuado manejo del dolor, se colocó asistencia ventilatoria mecánica. A las 72 horas, se decidió la resolución quirúrgica mediante osteosíntesis de las costillas 3a-7a. La paciente evolucionó favorablemente. El manejo quirúrgico permitió reducir los días de ventilación mecánica y de internación.
Assuntos
Tórax Fundido , Criança , Feminino , Tórax Fundido/etiologia , Tórax Fundido/terapia , Humanos , Respiração Artificial , Ferimentos não Penetrantes/complicaçõesRESUMO
We describe a patient with polytrauma that included anterior chest flail caused by a fall while climbing. As the situation was similar to a pectus excavatum, we attempted to stabilize the depressed chest wall by using a vacuum bell. Deep breath, peak flow, and pectus index were increased when the patient used the vacuum bell. Conservative treatment with a vacuum bell during the day and continuous positive airway pressure during the night was undertaken for 6 weeks. This report documents stabilization of an anterior flail chest using a vacuum bell.
Assuntos
Tórax Fundido/terapia , Sucção/instrumentação , Desenho de Equipamento , Feminino , Tórax Fundido/diagnóstico , Humanos , Imageamento Tridimensional , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X , VácuoRESUMO
PURPOSE: Flail chest was traditionally treated non-operatively using mechanical ventilation and pain control. In order to reduce the occurrence of ventilation-associated complications and long-term disability, operative rib fixation is becoming a proven standard therapy for these patients. However, the consequences of the surgical complications may influence success rates negatively. The aim of this study was to compare the outcome of flail chest treatment by surgical rib fixation with non-operative treatment, with special focus on the impact of surgical complications. METHODS: A retrospective case series of operatively treated flail chest patients was compared with non-operatively treated patients. Patients' injury and treatment characteristics and outcome parameters (e.g., duration of mechanical ventilation, length of Intensive Care stay (ICLOS) and hospital length of stay (HLOS), mortality, surgery-related complications and pneumonia) were collected from the patients' medical files. Crude and matched-pairs analyses were performed in SPSS. RESULTS: Twenty-three operatively and 47 non-operatively treated patients were enrolled. Operatively treated patients required significantly shorter mechanical ventilation; median 4 days versus 12 days for the non-operative group (p = 0.011). The matched-pairs analysis also showed a lower pneumonia rate (35% versus 80%; p = 0.035) and a shorter HLOS (median 21 versus 23 days; p = 0.028) in the operative group. No significant differences in duration of ICLOS, and occurrence of other injury-related adverse events were found between both groups. Seven surgery-related complications occurred, of which three required invasive solutions. CONCLUSIONS: Operative fixation of a flail chest in trauma patients results in a lower rate of pneumonia, less mechanical ventilation days and shorter hospital stay, compared with non-operative treatment, but at the cost of surgery-related complications requiring invasive solutions in some cases.
Assuntos
Tórax Fundido/terapia , Adulto , Idoso , Feminino , Tórax Fundido/cirurgia , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Pneumonia/epidemiologia , Complicações Pós-Operatórias , Respiração Artificial , Estudos Retrospectivos , Centros de TraumatologiaRESUMO
CASE: A patient sustained flail chest and diaphragmatic rupture with perforation of the stomach. She underwent gastrorrhaphy with chest lavage. She developed empyema and underwent decortication. Intraoperative cultures grew bacteria and yeast. She failed extubation because of pain despite maximal medical therapy. She underwent surgical stabilization of rib fractures (SSRF). Intraoperative cultures remained positive. She was extubated 9 days after SSRF. She was ultimately discharged to home with a total of 2 months of antibiotics and no need for plate removal. CONCLUSION: The presence of infection should not be considered a contraindication to SSRF in patients who are mechanical ventilation dependent due to flail chest.
Assuntos
Antibacterianos/uso terapêutico , Empiema Pleural/terapia , Tórax Fundido/terapia , Fixação Interna de Fraturas/métodos , Fraturas das Costelas/terapia , Terapia Combinada , Empiema Pleural/microbiologia , Feminino , Tórax Fundido/etiologia , Tórax Fundido/microbiologia , Humanos , Pessoa de Meia-Idade , Respiração Artificial/métodos , Fraturas das Costelas/etiologia , Fraturas das Costelas/microbiologiaRESUMO
INTRODUCTION: A trend has evolved towards rib fixation for flail chest although evidence is limited. Little is known about rib fixation for multiple rib fractures without flail chest. The aim of this study is to compare rib fixation with nonoperative treatment for both patients with flail chest and patients with multiple rib fractures. METHODS AND ANALYSIS: In this study protocol for a multicentre prospective cohort study, all patients with three or more rib fractures admitted to one of the five participating centres will be included. In two centres, rib fixation is performed and in three centres nonoperative treatment is the standard-of-care for flail chest or multiple rib fractures. The primary outcome measures are intensive care unit length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and length of stay. All analyses will be performed separately for patients with flail chest and patients with multiple rib fractures without flail chest. ETHICS AND DISSEMINATION: The regional Medical Research Ethics Committee UMC Utrecht approved a waiver of consent (reference number WAG/mb/17/024787 and METC protocol number 17-544/C). Patients will be fully informed of the purpose and procedures of the study, and signed informed consent will be obtained in agreement with the General Data Protection Regulation. Study results will be submitted for peer review publication. TRIAL REGISTRATION NUMBER: NTR6833.
Assuntos
Tórax Fundido/terapia , Fraturas das Costelas/terapia , Traumatismos Torácicos/terapia , Ferimentos não Penetrantes/terapia , Adulto , Ensaios Clínicos como Assunto , Feminino , Tórax Fundido/etiologia , Tórax Fundido/cirurgia , Fixação de Fratura , Custos de Cuidados de Saúde , Humanos , Masculino , Estudos Prospectivos , Fraturas das Costelas/etiologia , Fraturas das Costelas/cirurgia , Traumatismos Torácicos/complicações , Traumatismos Torácicos/cirurgia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/cirurgiaRESUMO
INTRODUCTION: The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in trauma patients has been controversial, but VV-ECMO plays a crucial role when the lungs are extensively damaged and when conventional management has failed. VV-ECMO provides adequate tissue oxygenation and an opportunity for lung recovery. However, VV-ECMO remains contraindicated in patients with a risk of bleeding because of systemic anticoagulation during the treatment. The most important point is controlling the bleeding from severe trauma. CASE: A 32-year-old male experienced blunt trauma due to a traffic accident. He presented with bilateral hemopneumothorax and bilateral flail chest. We performed emergency thoracotomy for active bleeding and established circulatory stability. After surgery, the oxygenation deteriorated under mechanical ventilation, so we decided to establish VV-ECMO. However, bleeding from the bilateral lung contusions increased after VV-ECMO was established, and the patient was switched to heparin-free ECMO. After conversion, we could control the bronchial bleeding, especially the lung hematomas, and the oxygenation recovered. The patient was discharged without significant complications. VV-ECMO and mechanical ventilation were stopped on days 10 and 11, respectively. He was discharged from the ICU on day 15. CONCLUSION: When we consider the use of ECMO for patients with uncontrollable, severe bleeding caused by blunt trauma, it may be necessary to use a higher flow setting for heparin-free ECMO than typically used for patients without trauma to prevent thrombosis.
Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Hemorragia/terapia , Traumatismos Torácicos/terapia , Ferimentos não Penetrantes/terapia , Acidentes de Trânsito , Adulto , Tórax Fundido/terapia , Hemopneumotórax/terapia , Hemorragia/etiologia , Humanos , Masculino , Motocicletas , Respiração Artificial , ToracotomiaRESUMO
RATIONALE: Rib fractures are common among patients with blunt chest wall trauma and often represent life-altering injuries. PATIENT CONCERNS: A 31-year-old woman presented with right chest trauma, with pain and bleeding as a result of a traffic accident 1 hour previously. DIAGNOSES: Chest computed tomography showed open chest trauma, multiple rib fractures, flail chest, hemopneumothorax, and lung contusion on the right side. INTERVENTIONS: We decided to perform debridement via emergency, thoracoscopic exploration to remove blood and contaminants from the chest cavity. Thereafter, the third to seventh fractured ribs were fixed and reconstructed using the matrix rib internal fixation system, followed by suturing of the incision according to the original anatomical level. OUTCOMES: The patient was discharged 15 days after surgery, and recovered well with satisfactory results. LESSONS: We believe that initial chest reconstruction with internal fixation in the first stage following thorough debridement may be suitable for treating flail chest, and could save the patient's life in the early stages. However, the decision to perform the first-stage operation for the open contaminated wound should be carefully considered.
Assuntos
Acidentes de Trânsito , Fixação Interna de Fraturas/métodos , Fixadores Internos , Fraturas das Costelas/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Desbridamento/métodos , Feminino , Tórax Fundido/terapia , Humanos , Fraturas das Costelas/terapia , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/terapiaRESUMO
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.
Assuntos
Tórax Fundido/terapia , Fixação Interna de Fraturas/métodos , Fraturas das Costelas/terapia , Adulto , Tórax Fundido/mortalidade , Fixação Interna de Fraturas/mortalidade , Humanos , Tempo de Internação/estatística & dados numéricos , Pneumonia/etiologia , Pneumonia/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial/mortalidade , Respiração Artificial/estatística & dados numéricos , Fraturas das Costelas/mortalidade , Revisões Sistemáticas como AssuntoRESUMO
Prone ventilation is used to manage patients with refractory hypoxia in the critical care unit. Complex chest trauma and chest drains have been a considered relative contraindication to prone ventilation. To the best of our knowledge, it is hitherto unreported in patients having traumatic floating sternum and acute respiratory distress. We present a brief case report of a patient with floating sternum (complete disruption of sternum) managed successfully by prone position ventilation.
Assuntos
Tórax Fundido/terapia , Hipóxia/terapia , Posicionamento do Paciente/métodos , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/terapia , Traumatismos Torácicos/terapia , Acidentes de Trânsito , Analgesia Epidural , Tubos Torácicos , Drenagem , Tórax Fundido/complicações , Hemotórax/complicações , Hemotórax/terapia , Humanos , Hipotensão/complicações , Hipotensão/terapia , Hipóxia/complicações , Masculino , Pessoa de Meia-Idade , Norepinefrina/uso terapêutico , Decúbito Ventral , Síndrome do Desconforto Respiratório/complicações , Articulações Esternocostais , Traumatismos Torácicos/complicações , Vasoconstritores/uso terapêuticoRESUMO
OBJECTIVE: Rib fractures are common injuries sustained by patients who experience high-impact chest trauma, and they result in severe respiratory compromise because of the altered mechanics of respiration. Several studies have shown that the ventilation requirements and incidence of pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate the effect of surgical fixation treatments for rib fractures through systematic review and meta-analysis. METHODS: A literature search was performed in the PubMed, EMBASE, Web of Science and Cochrane Library databases for information from February 1958 to April 2018. Studies comparing the benefits of surgical management with that of non-surgical management of rib fractures were included. Statistical heterogeneity was evaluated by the X2 test with the significance set to P < 0.10 or I2 > 50%. RESULTS: Fourteen studies consisting of 839 patients were included (407 patients in the surgical management group; 432 patients in the non-surgical management group). The results showed that the surgical management group experienced a significant decrease in hospitalization time, intensive care time, mechanical ventilation time, mortality rate, pulmonary infection rate and tracheotomy rate compared with the non-surgical management group. However, the surgical management group incurred extra costs, and there was no significant difference in the duration of antibiotic use between the two groups. CONCLUSIONS: Compared with non-surgical management, surgical management methods are of great value in the treatment of rib fractures despite the added expense.
Assuntos
Tratamento Conservador/métodos , Tórax Fundido/terapia , Fixação de Fratura/métodos , Fraturas das Costelas/terapia , Tratamento Conservador/efeitos adversos , Feminino , Fixação de Fratura/efeitos adversos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Respiração Artificial/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: Over the years, a trend has evolved towards operative treatment of flail chest although evidence is limited. Furthermore, little is known about operative treatment for patients with multiple rib fractures without a flail chest. The aim of this study was to compare rib fixation based on a clinical treatment algorithm with nonoperative treatment for both patients with a flail chest or multiple rib fractures. METHODS: All patients with ≥ 3 rib fractures admitted to one of the two contributing hospitals between January 2014 and January 2017 were retrospectively included in this multicenter cohort study. One hospital treated all patients nonoperatively and the other hospital treated patients with rib fixation according to a clinical treatment algorithm. Primary outcome measures were intensive care length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. To control for potential confounding, propensity score matching was applied. RESULTS: A total of 332 patients were treated according to protocol and available for analysis. The mean age was 56 (SD 17) years old and 257 (77%) patients were male. The overall mean Injury Severity Score was 23 (SD 11) and the average number of rib fractures was 8 (SD 4). There were 92 patients with a flail chest, 37 (40%) had rib fixation and 55 (60%) had non-operative treatment. There were 240 patients with multiple rib fractures, 28 (12%) had rib fixation and 212 (88%) had non-operative treatment. For both patient groups, after propensity score matching, rib fixation was not associated with intensive care unit length of stay (for flail chest patients) nor with hospital length of stay (for multiple rib fracture patients), nor with the secondary outcome measures. CONCLUSION: No advantage could be demonstrated for operative fixation of rib fractures. Future studies are needed before rib fixation is embedded or abandoned in clinical practice.
Assuntos
Tórax Fundido/terapia , Fraturas Múltiplas/terapia , Fraturas das Costelas/terapia , Ferimentos não Penetrantes/terapia , Acidentes por Quedas/estatística & dados numéricos , Acidentes de Trânsito/estatística & dados numéricos , Estudos de Coortes , Cuidados Críticos/estatística & dados numéricos , Feminino , Fixação de Fratura/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Traumatismos Torácicos/terapia , Resultado do TratamentoRESUMO
PURPOSE: The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. METHODS: MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy. RESULTS: Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I2 = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies. CONCLUSIONS: Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.