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1.
Ann Palliat Med ; 9(5): 3710-3715, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33065808

RESUMO

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a newly identified strain of coronavirus in the human body and was reported in Wuhan at the end of 2019. So far, the epidemic is continuing and very serious, with the number of infections and deaths increasing. Despite active investigations around the world to better understand the dynamics of transmission and the scope of clinical disease, COVID-19 continues to spread rapidly from person to person. The common signs and symptoms of SARS-CoV-2 infection include fever, fatigue, dry cough, and dyspnea; in severe cases, patients may have acute respiratory distress syndrome, septic shock, metabolic acidosis difficult to treat and coagulation disorder. However, some patients who test positive for SARS-CoV-2 in their respiratory tract may not have such clinical signs and symptoms. This report presents a case study analysis of a patient admitted in the Fourth Taiyuan People's Hospital, who had suffered traumatic injuries from a car accident and survived COVID-19, with pleural effusion as the initial symptom. We report a case of 2019-NCOV with pleural effusion as the first symptom. Describe in detail the differential diagnosis, diagnosis, clinical management, and cure of this case. In order to combat the novel CoronaviruscoVID-19 in the process to provide lessons and help.


Assuntos
Acidentes de Trânsito , Infecções por Coronavirus/diagnóstico , Traumatismo Múltiplo/diagnóstico , Derrame Pleural/diagnóstico , Pneumonia Viral/diagnóstico , Adulto , Betacoronavirus , Otorreia de Líquido Cefalorraquidiano/complicações , Otorreia de Líquido Cefalorraquidiano/diagnóstico , Infecções por Coronavirus/complicações , Progressão da Doença , Sinusite Etmoidal/complicações , Sinusite Etmoidal/diagnóstico , Feminino , Traumatismos do Pé/complicações , Traumatismos do Pé/diagnóstico , Humanos , Pulmão/diagnóstico por imagem , Fraturas Maxilares/complicações , Fraturas Maxilares/diagnóstico , Seio Maxilar/lesões , Traumatismo Múltiplo/complicações , Fraturas Orbitárias/complicações , Pandemias , Derrame Pleural/etiologia , Pneumonia Viral/complicações , Fraturas das Costelas/complicações , Fraturas das Costelas/diagnóstico , Falanges dos Dedos do Pé/lesões , Tomografia Computadorizada por Raios X , Fraturas da Ulna/complicações , Fraturas da Ulna/diagnóstico
2.
Am Surg ; 86(8): 926-932, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32749863

RESUMO

BACKGROUND: Rib fractures are common injuries among traumatically injured patients, and elderly patients with rib fractures are at increased risk for adverse events and death. The purpose of this study was to determine if oral Per os (PO) acetaminophen is as effective as intravenous (IV) acetaminophen in treating the pain associated with rib fractures. METHODS: We performed a single-center, randomized, placebo-controlled, double-blinded study. Trauma patients who were ≥65 years old and had ≥1 rib fracture were included in this study. Patients were randomized into IV acetaminophen and oral placebo (n = 63) or IV placebo and oral solution acetaminophen (n = 75) groups. The primary outcome was a mean reduction in pain score at 24 hours, and secondary outcomes included opioid use, intensive care unit (ICU) length of stay (LOS), hospital LOS, hospital mortality, the difference in incentive spirometry, and development of pneumonia. RESULTS: Among the 138 patients included, there was no statistically significant difference between the 2 study groups in a mean reduction in pain score at 24 hours after injury (PO: 3.24, IV: 2.49; P = .230). Opioid pain medication use was equivalent between groups (P = .212), and there was no significant difference in hospital mortality rate between groups (P = .827). There was no statistically significant difference in ICU LOS, hospital LOS, or development of pneumonia. DISCUSSION: In elderly trauma patients (age ≥65 years) with 1 or more rib fractures, PO acetaminophen is equivalent to IV acetaminophen for pain control, with no difference in morbidity or mortality. Oral acetaminophen should be preferentially used over IV acetaminophen when treating the elderly trauma patient with rib fractures.


Assuntos
Acetaminofen/administração & dosagem , Dor Aguda/tratamento farmacológico , Analgésicos não Entorpecentes/administração & dosagem , Dor Musculoesquelética/tratamento farmacológico , Fraturas das Costelas/complicações , Acetaminofen/uso terapêutico , Dor Aguda/etiologia , Administração Intravenosa , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Analgésicos não Entorpecentes/uso terapêutico , Método Duplo-Cego , Feminino , Humanos , Masculino , Dor Musculoesquelética/etiologia , Estudos Prospectivos , Resultado do Tratamento
3.
Surgery ; 168(4): 684-689, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32653204

RESUMO

BACKGROUND: Rib fractures are painful injuries that are treated with aggressive analgesia, which can include opioids. We sought to evaluate the patterns and predictors of opioid prescription and sustained use for rib fracture patients to identify opportunities for opiate reduction. METHODS: We used TRICARE claims data (2006-2014) to identify adult (18-64 years) patients presenting to the emergency department with rib fracture(s) and isolated chest trauma. We used logistic regression and Cox proportional hazards model to identify factors associated with opioid prescription and duration of use. RESULTS: We identified 29,943 patients meeting inclusion criteria, and 2,542 (9%) patients were prescribed opioids. When prescribed, the median duration opioid use was 16 days (interquartile range 6-31) for opioid naïve patients, compared with 36 days (interquartile range 15-134) for those with prior opioid exposure. Increased number of ribs fractured (6+ fractures) (odds ratio 2.96 [95% confidence interval 2.23-3.94], P < .001) and prior opioid exposure (odds ratio 32.95 [29.36-36.99], P < .001) were significant predictors of initial opioid prescription. Patients with prior opioid exposure (hazard ratio 0.47 [0.43-0.52], P < .001) had lower likelihood of opioid discontinuation. Injury characteristics did not significantly predict discontinuation. CONCLUSION: Prior opioid exposure was the strongest predictor of sustained opioid use after rib fractures, while the severity of injury did not predict the duration of use.


Assuntos
Analgésicos Opioides/uso terapêutico , Manejo da Dor/métodos , Padrões de Prática Médica , Fraturas das Costelas/complicações , Adolescente , Adulto , Procedimentos Clínicos , Esquema de Medicação , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Fraturas Múltiplas/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Adulto Jovem
4.
J Surg Res ; 255: 556-564, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32640407

RESUMO

BACKGROUND: Alcohol use disorder (AUD) has deleterious effects on many organ systems. The aim of our study was to assess the impact of AUD on outcomes in patients with rib fractures. We hypothesized that AUD is associated with increased risk adverse outcomes. METHODS: We performed a 2013-2014 retrospective analysis of all adult trauma patients diagnosed with rib fractures from the American College of Surgeons-Trauma Quality Improvement Program database. We excluded patients who were acutely intoxicated with alcohol. Patients were stratified into two groups: AUD + and AUD -. A 1:1 ratio propensity score matching for demographics, admission vitals, injury severity, smoking status, operative intervention, and number of rib fractures was performed. Outcome measures were in-hospital complications, mortality, hospital and intensive care unit length of stay, and ventilator days. RESULTS: We matched 19,638 patients (AUD +:9,819, AUD -:9819). Mean age was 53 ± 22y, and median injury severity score was 15[10-20]. Matched groups were similar in age (P = 0.18), smoking status (P = 0.82), injury severity score (P = 0.28), chest Abbreviated Injury Scale (P = 0.24), and number of rib fractures (2[1-4] versus 2[1-4], P = 0.86). Alcoholic patients had higher rates of pneumonia (18.1% versus 9.2%, P < 0.01), unplanned intubation (18.5% versus 9.7, P < 0.001), sepsis (10.8% versus 6.3%, P < 0.001), acute respiratory distress syndrome (12.2% versus 7.4%, P < 0.001), and mortality (8.0 versus 5.7%, P < 0.001). Patients with AUD spent more days in the hospital and intensive care unit . There was no difference in ventilator days between the two groups. CONCLUSIONS: Patients with AUD and rib fractures had higher rates of adverse events than patients without AUD. Early identification of patients with rib fractures with AUD may allow better resource allocation and help improve outcomes. LEVEL OF EVIDENCE: Level III prognostic.


Assuntos
Alcoolismo/epidemiologia , Pneumonia/epidemiologia , Fraturas das Costelas/terapia , Sepse/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Alcoolismo/complicações , Comorbidade , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Intubação/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pneumonia/etiologia , Pneumonia/terapia , /terapia , Estudos Retrospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/diagnóstico , Fraturas das Costelas/mortalidade , Fatores de Risco , Sepse/etiologia , Sepse/terapia , Centros de Traumatologia/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto Jovem
5.
Ulus Travma Acil Cerrahi Derg ; 26(4): 531-537, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32589244

RESUMO

BACKGROUND: This prospective study aims to investigate the effect of chest physiotherapy and analgesic therapy on the possible complications of isolated rib fractures attributable to blunt thoracic trauma, such as hemothorax and pneumothorax. METHODS: Patients who presented to Çanakkale Onsekiz Mart University School of Medicine Hospital's Emergency Department and Thoracic Surgery outpatient clinics within the first 24 hours of the post-traumatic period and did not have additional intrathoracic complications at presentation with blunt thoracic trauma and who were diagnosed with isolated rib fractures were enrolled in this prospective research study. The groups were designated as the patients who would receive analgesic treatment only (Group A) and the patients who would receive chest physiotherapy and analgesic treatment together (Group B). Patients who had first and second rib fractures or three or more rib fractures and who did not have additional organ injury were hospitalized in the Thoracic Surgery clinics; patients who had other organ trauma were hospitalized in related clinics. Patients were reassessed on their seventh and 30th post-traumatic days with physical examination and radiologic studies. RESULTS: The mean age of the 114 patients were 56.3±16.4 (22-87). There were 37 (32.5%) women and 77 (67.5%) men. Each group included 57 patients. The most common form of trauma was the same-level falls (31.6%). The mean number of rib fractures of all participants was 2.6±0.7 (1-10); the median number was 1.5. Fifty-two (45.6%) patients were hospitalized. The mean length of stay was 4.0±1.1 days. At the end of their treatment and follow-up periods, pleural effusion was found in 28 patients (24.6%) out of 114 enrolled at the side of trauma. Group B had a higher number of patients with pleural effusion (43.9%) than group A (5.3%). We performed tube thoracostomy in four patients, all of which were in group B (p<0.05). CONCLUSION: As a result of this study, chest physiotherapy maneuvers have increased the incidence of late hemothorax in patients with three or more isolated rib fractures. Also, minimal hemothoraces (<300 ml) may spontaneously regress, and no additional surgical treatment are required if the proper follow-up procedures are performed. It is advisable to hospitalize the blunt thoracic trauma patients who have three or more rib fractures and who are planned to undergo chest physiotherapy and or are prone to develop additional complications because of possible risks.


Assuntos
Analgésicos/uso terapêutico , Modalidades de Fisioterapia/efeitos adversos , Fraturas das Costelas , Ferimentos não Penetrantes , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemotórax/etiologia , Hemotórax/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Pneumotórax/etiologia , Pneumotórax/prevenção & controle , Estudos Prospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/terapia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/terapia , Adulto Jovem
7.
BMC Surg ; 20(1): 87, 2020 May 05.
Artigo em Inglês | MEDLINE | ID: mdl-32370809

RESUMO

BACKGROUND: Severe flail chest is a life-threatening situation. The Nuss procedure is a new effective treatment for severe flail chest patients who cannot be weaned from prolonged mechanical ventilation in the last few years. However, the procedure is not suitable when there are multiple fractures in both the anterior and lateral chest walls. Here, we reported a rare case of severe flail chest in a patient who suffered multiple fractures in both the anterior and lateral chest walls in a traffic accident. CASE PRESENTATION: A 49-year-old patient suffered severe flail chest by a steering wheel in a traffic accident with multiple fractures in both the anterior and lateral chest walls. In the beginning, the patient was administrated with mechanical ventilation because of acute respiratory distress syndrome (ARDS) for more than 1 week. Then the patient suffered from a severe lung infection and decreased blood oxygen saturation. After a multidiscipline discussion (MDT), three rib fixation plates were first used to rebuild the stability of lateral chest walls, then two Nuss bars were inserted to eliminate paradoxical movement in the anterior chest wall. Finally, the patient recovered smoothly after the combining procedure. CONCLUSIONS: Severe flail chest patients with both the anterior and lateral chest walls after trauma are in a life-threatening situation, and require an appropriate procedure to get out of danger in time. Rib fixation is an effective treatment when the fractured sites are few and the fractured area is small. The Nuss procedure is a new effective method for severe flail chest with multiple fractures in an anterior chest wall, which is also a minimally invasive and short time-consuming procedure. However, it does not suitable for the patient with multiple fractures in lateral chest walls. Combining the use of Nuss procedure and rib fixation can solve severe flail chest with multiple ribs and sternum fractures in both the anterior and lateral chest walls, and the outcome of this procedure is satisfying in the present rare case.


Assuntos
Tórax Fundido/cirurgia , Fixação Interna de Fraturas/métodos , Fraturas das Costelas/complicações , Acidentes de Trânsito , Humanos , Masculino , Pessoa de Meia-Idade , Costelas/lesões , Esterno/lesões , Resultado do Tratamento
8.
J Cardiothorac Surg ; 15(1): 91, 2020 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-32398105

RESUMO

BACKGROUND: Thoracic surgeons have been incorporating enhanced recovery after surgery (ERAS) protocols into their practices, not only to reduce narcotic usage but also to improve complication rates and decrease lengths of stay. Here, we describe the utility of a regional block technique that can be used for patients undergoing urgent or elective thoracic surgical procedures or suffering from rib fractures. METHODS: We report our initial one-year experience with these erector spinae plane (ESP) blocks. RESULTS: ESP blocks were placed in 42 patients. The procedure was performed by a trained team of anesthesiologists and certified nurse practitioners. It included placement of a catheter on the ipsilateral chest, followed by a 20 ml of 0.2% ropivacaine bolus and continuous infusion. Patients were then followed by the regional team, as long as the catheter was in place. While it had some technical challenges, the block was effective in 83.3% of patients with no reported mortality or major complications. However, given the confounding factors of the study (such as simultaneous implementation of ERAS protocol) and heterogeneity of the patient population, a control group was difficult to ascertain and meaningful opioid consumption analysis was difficult to perform. CONCLUSIONS: Regional blocks, such as the ESP block, complement fundamental ERAS principles and serve as an adjunct to the available armamentarium for non-narcotic ways to control pain in thoracic surgical and chest trauma patients. Continued collaboration between the thoracic surgeons and anesthesiologists is needed for its success.


Assuntos
Anestésicos Locais , Dor Musculoesquelética/terapia , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Músculos Paraespinais , Ropivacaina , Adulto , Idoso , Idoso de 80 Anos ou mais , Recuperação Pós-Cirúrgica Melhorada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Musculoesquelética/etiologia , Fraturas das Costelas/complicações , Procedimentos Cirúrgicos Torácicos , Tórax
9.
Am J Med ; 133(10): 1135-1142, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32442508

RESUMO

Chest pain is a common presenting complaint in the primary care setting. Imaging plays a key role in the evaluation of the multiple organ systems that can be responsible for chest pain. With numerous imaging modalities available, determination of the most appropriate test and interpretation of the findings can be a challenge for the clinician. In this 2-part series, we offer resources to guide primary care physicians in the selection of imaging studies and present the imaging findings of various causes of nonemergent chest pain. In Part 2, we focus on the radiologic appearance of common noncardiac sources of chest pain, including gastrointestinal, pulmonary, and musculoskeletal etiologies.


Assuntos
Dor no Peito/etiologia , Transtornos da Motilidade Esofágica/diagnóstico por imagem , Hérnia Hiatal/diagnóstico por imagem , Doenças Musculoesqueléticas/diagnóstico por imagem , Atenção Primária à Saúde , Doenças Respiratórias/diagnóstico por imagem , Transtornos da Motilidade Esofágica/complicações , Fraturas por Compressão/complicações , Fraturas por Compressão/diagnóstico por imagem , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/diagnóstico por imagem , Hérnia Hiatal/complicações , Humanos , Imagem por Ressonância Magnética , Doenças Musculoesqueléticas/complicações , Derrame Pleural/complicações , Derrame Pleural/diagnóstico por imagem , Pneumonia/complicações , Pneumonia/diagnóstico por imagem , Pneumotórax/complicações , Pneumotórax/diagnóstico por imagem , Radiografia Torácica , Doenças Respiratórias/complicações , Fraturas das Costelas/complicações , Fraturas das Costelas/diagnóstico por imagem , Fraturas da Coluna Vertebral/complicações , Fraturas da Coluna Vertebral/diagnóstico por imagem , Parede Torácica/diagnóstico por imagem , Síndrome de Tietze/complicações , Síndrome de Tietze/diagnóstico por imagem , Tomografia Computadorizada por Raios X
10.
J Trauma Acute Care Surg ; 89(1): 96-102, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32282755

RESUMO

BACKGROUND: Rib fractures following blunt trauma are a major cause of morbidity. Various factors have been used for risk stratification for complications. Ultrasound (US) measurements of diaphragm thickness (Tdi) and related measures such as thickening fraction (TF) have been verified for use in the evaluation of diaphragm function. In healthy individuals, Tdi by US is known to have a positive and direct relationship with lung volumes including inspiratory capacity (IC). However, TF has not been previously been described in, or used to assess, pulmonary function in rib fracture patients. We examined TF and IC to elucidate the association between acute rib fractures and respiratory function. We hypothesized that TF and IC were related. Secondarily, we examined the relationship of TF in rib fractures patients, in the context of values reported for healthy controls in the literature. METHODS: We prospectively enrolled adults with acute blunt traumatic rib fractures within 48 hours of admission to a level 1 trauma center. Patients requiring a chest tube or mechanical ventilation at time of consent were excluded. Inspiratory capacity was determined via incentive spirometry. Thickening fraction was determined by bedside US measurements of minimum and maximum Tdi during tidal breathing (TFtidal) or deep breathing (TFDB) was calculated (TF = [TdimaxTdi - TdiminTdi]/TdiminTdi). TFDB values were also compared with previously reported mean ± SD values of 2.04 ± 0.62 in healthy males and 1.70 ± 0.89 in females. Univariate and multivariate analyses were performed. RESULTS: A total of 41 subjects (58.5% male) with a median age of 64 years (interquartile range [IQR], 53-77 years) were enrolled. Diaphragm US demonstrated a median TFtidal of 0.30 (IQR, 0.24-0.46). Median IC was 1,750 mL (IQR, 1,250-2,000 mL). As compared with previously reported controls, our mean ± SD TFDB in males 0.90 ± 0.51 and 0.88 ± 0.89 in females were significantly lower. Multivariate analysis revealed a significant inverse correlation (-0.439, p = 0.004) between TFtidal and IC, and no relationship between TFDB and IC. CONCLUSION: To our knowledge, this is the first report of TF in rib fracture patients. The significant inverse association between TFtidal and IC, along with lower than normal TFDB ranges, suggests that, in the setting of rib fractures, there are alterations in the diaphragm-chest cage mechanics, whereby other muscles may play more prominent roles. LEVEL OF EVIDENCE: Diagnostic tests or criteria, Level III.


Assuntos
Diafragma/diagnóstico por imagem , Fraturas das Costelas/complicações , Ultrassonografia/métodos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Testes de Função Respiratória , Centros de Traumatologia
11.
JBJS Case Connect ; 10(1): e0011, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32224659

RESUMO

CASE: A 33-year-old man with recurrent intrathoracic scapular dislocation due to previous trauma-related chest wall resection successfully underwent the 2-stage induced membrane technique commonly known as the Masquelet technique; this procedure effectively created 2 new ribs that resolved his symptoms. CONCLUSIONS: Techniques for chest wall reconstruction for bone loss are quite limited, and these often consist of filling defects with a layered patch; this often cannot withstand the cyclical respiratory motion. Use of the induced membrane technique appears to carry potential when used in the chest wall, and this report describes a technique by which this procedure can be reliably performed.


Assuntos
Transplante Ósseo/métodos , Tórax Fundido/complicações , Fraturas não Consolidadas/complicações , Fraturas das Costelas/complicações , Parede Torácica/cirurgia , Adulto , Clavícula/lesões , Clavícula/cirurgia , Humanos , Masculino , Procedimentos Cirúrgicos Reconstrutivos , Parede Torácica/diagnóstico por imagem
13.
Am J Emerg Med ; 38(6): 1203-1208, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32107130

RESUMO

INTRODUCTION: Peripheral nerve blocks and regional anesthesia are routinely used to alleviate pain in the emergency department. Our objective is to report on the feasibility and initial experience of emergency physicians initiating and managing continuous nerve blocks for trauma patients. METHODS: This was a retrospective, observational cohort study of a convenience sample of patients 18 years or older presenting with either rib or hip fractures between August 15, 2016 and January 15, 2019. Demographic and clinical data was abstracted using a structured data collection form. Data collected included basic demographics, mechanism of injury, type of regional anesthesia, admission location, respiratory complications, pre- and post-procedure opioid use, efficacy of anesthesia and duration of continuous nerve blockade. All analyses were descriptive in nature, including means, median, and range when appropriate. RESULTS: Forty-one patients presented during the study period with rib or hip fractures and received a nerve block catheter and a continuous infusion pump. The mean age of patients was 65.9 years and 26 (63.4%) patients were male. The mean duration of continuous nerve blockade was 3.4 days (range 1-9 days). Hourly opioid use was reduced by 58%. The most common complication was accidental dislodgement of the catheter;, no patient developed a pneumothorax, hemothorax, catheter related infection, or hematoma. CONCLUSIONS: It is feasible and effective for emergency physicians to initiate and manage continuous nerve blockade for acute hip and rib fractures. Continuous nerve blockade may allow trauma patients to significantly decrease their use of opioids.


Assuntos
Bloqueio Nervoso/normas , Manejo da Dor/normas , Médicos/psicologia , Adulto , Idoso , Anestésicos Locais/uso terapêutico , Medicina de Emergência/métodos , Medicina de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Fraturas do Quadril/complicações , Fraturas do Quadril/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/métodos , Bloqueio Nervoso/estatística & dados numéricos , Manejo da Dor/estatística & dados numéricos , Medição da Dor/métodos , Médicos/estatística & dados numéricos , Estudos Retrospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/tratamento farmacológico , Ropivacaina/uso terapêutico , Fatores de Tempo , Resultado do Tratamento
14.
J Trauma Acute Care Surg ; 88(2): 249-257, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31804414

RESUMO

BACKGROUND: The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with displaced rib fractures in the absence of flail chest. METHODS: Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared. RESULTS: One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02). CONCLUSION: In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest. LEVEL OF EVIDENCE: Therapeutic, level II.


Assuntos
Fixação de Fratura/métodos , Fraturas Múltiplas/cirurgia , Hemotórax/epidemiologia , Dor Pós-Operatória/diagnóstico , Fraturas das Costelas/cirurgia , Adolescente , Adulto , Idoso , Feminino , Fraturas Múltiplas/complicações , Fraturas Múltiplas/diagnóstico , Hemotórax/etiologia , Hemotórax/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/terapia , Estudos Prospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/diagnóstico , Índices de Gravidade do Trauma , Resultado do Tratamento , Adulto Jovem
16.
J Surg Res ; 246: 476-481, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31668607

RESUMO

INTRODUCTION: Rib fractures are a major problem in trauma patients, and the associated pain is not well understood. Measuring total pain experience, duration, and intensity could facilitate comparisons of treatments. This study was intended to evaluate the feasibility of quantifying pain over the course of an admission and identify factors associated with increased pain experience in adults with rib fractures. METHODS: Patients admitted to a level I trauma center with rib fractures between 2015 and 2017 were included. Maximum pain score (verbal or nonverbal) was captured for each hospital day. Total pain was defined as the sum of the area under the curve (AUC) of the max pain scores plotted against time. A general linear model was used to determine demographic, injury, and clinical predictors of the pain AUC. RESULTS: We identified 3713 patients. Increased pain experienced (greater AUC) was associated with age group 40-59 y compared with 18-39 y (B = 6.1, P = 0.002); Injury Severity Score 9-14 (B = 11.5, P < 0.001) and ≥16 (B = 36.9, P < 0.0001); patients with flail chest versus multiple rib fractures (B = 17.1, P < 0.001); and patients who underwent rib fixation (B = 20.7, P = 0.004). Decreased pain experience was observed for male gender (B = -3.7, P = 0.032) and blunt mechanism of injury (B = -13.7, P < 0.0001). CONCLUSIONS: This study demonstrates the feasibility of measuring patients' total pain experience over the duration of their admission. Pain is a subjective but relevant measure of patients' experience. Our study identifies a number of predictive factors, some expected and some unexpected. Increased overall experience pain following fixation may be the result of severe pain before intervention.


Assuntos
Tórax Fundido/diagnóstico , Fixação Interna de Fraturas/efeitos adversos , Dor Musculoesquelética/diagnóstico , Medição da Dor/métodos , Fraturas das Costelas/complicações , Adolescente , Adulto , Fatores Etários , Estudos de Viabilidade , Feminino , Tórax Fundido/etiologia , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Dor Musculoesquelética/etiologia , Estudos Retrospectivos , Fraturas das Costelas/diagnóstico , Fraturas das Costelas/cirurgia , Índice de Gravidade de Doença , Fatores Sexuais , Fatores de Tempo , Centros de Traumatologia/estatística & dados numéricos , Adulto Jovem
17.
J Surg Res ; 245: 492-499, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31446191

RESUMO

BACKGROUND: Older adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care. MATERIALS AND METHODS: We analyzed patients ≥50 y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs. RESULTS: Among 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry <1 L (OR 4.72, 95% CI 2.14-10.45); use of a walker (OR 2.86, 95% CI 1.29-6.34); increased chest Abbreviated Injury Scale score (AIS 3 OR 5.83, 95% CI 2.34-14.50); age ≥72 y (OR 2.68, 95% CI 1.48-4.86); and active smoking (OR 2.11, 95% CI 1.06-4.20). CONCLUSIONS: Routine ICU admission is not necessary for most older adults with isolated rib fractures. The predictors we identified warrant prospective evaluation for development of a clinical decision rule to preclude unnecessary ICU admissions.


Assuntos
Hipotensão/epidemiologia , Unidades de Terapia Intensiva/normas , Admissão do Paciente/normas , Fraturas das Costelas/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/normas , Cuidados Críticos/estatística & dados numéricos , Feminino , Humanos , Hipotensão/etiologia , Hipotensão/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fraturas das Costelas/complicações , Medição de Risco , Centros de Traumatologia/normas , Centros de Traumatologia/estatística & dados numéricos
18.
PLoS One ; 14(12): e0224105, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31856165

RESUMO

Rib fractures represent the most common bone fracture, occurring in 10-20% of all blunt trauma patients and leading to concomitant injuries of the inner organs in severe cases. The purpose of this study was to identify specific serial rib fracture patterns after blunt chest trauma. 380 serial rib fracture cases were investigated. Fractures were assigned to five different locations within the transverse plane. Rib level, fracture type, and dislocation grades were recorded and related to the cause of accident. In total, 3735 rib fractures were identified (9.8 per patient). 54% of the rib fractures were detected on the left thorax. Rib fracture distribution exhibited a hotspot at rib levels 4 to 7 in the lateral and posterolateral segments. On average, most rib fractures occurred in crush/burying injuries (15.8, n = 13) and pedestrian accidents (12.8, n = 13), least in car/truck accidents (8.9, n = 75). In the car/truck accident group, 47% of all rib fractures were in the lateral segment, in case of frontal collision (n = 24) even 60%. Fall injuries (n = 141) entailed mostly posterolateral rib fractures (35%). In case of falls >3 m (n = 45), 48% more rib fractures were detected on the left thorax. In cardiopulmonary resuscitation related serial rib fractures (n = 33), 70% of all rib fractures were located anterolaterally. Infractions were the most observed fracture type (44%), followed by oblique (25%) and transverse (18%) fractures, while 46% of all rib fractures were dislocated (15% ≥ rib width). Serial rib fractures showed distinct fracture patterns depending on the cause of accident. When developing a serial rib fracture classification system, data regarding patterns, fracture types, dislocation grades, and associated fractures should be included.


Assuntos
Fraturas das Costelas/complicações , Fraturas das Costelas/epidemiologia , Traumatismos Torácicos/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Alemanha , Humanos , Luxações Articulares/complicações , Masculino , Pessoa de Meia-Idade , Costelas , Tórax , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/epidemiologia
19.
Am Surg ; 85(10): 1134-1138, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657309

RESUMO

Traumatic esophageal injury is a highly lethal but rare injury with minimal data in the trauma population. We sought to provide a descriptive analysis of esophageal trauma (ET) to identify the incidence, associated injuries, interventions, and outcomes. We hypothesized that blunt trauma is associated with higher risk of death than penetrating trauma. The Trauma Quality Improvement Program (2010-2016) was queried for patients with ET. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U tests. A multivariable logistic regression model was used to determine risk of mortality. Of 1,403,466 adult patients, 651 (<0.01%) presented with ET. The most common associated thoracic injuries were rib fractures (38.7%) and pneumothorax (26.7%). More patients with a penetrating mechanism underwent open repair of the esophagus than those with blunt mechanism (46.2% vs 11.7%, P < 0.001). After controlling for covariates, there was no difference in risk of mortality between blunt and penetrating trauma (P = 0.65). The mortality rate for patients with esophageal injury surviving greater than 24 hours was 7.5 per cent. In this large national database analysis, ET was rare and most commonly associated with rib fractures and pneumothorax. Contrary to our hypothesis, the risk of mortality was equivalent between blunt and penetrating ET.


Assuntos
Esôfago/lesões , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/mortalidade , Adulto , Distribuição de Qui-Quadrado , Esôfago/cirurgia , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Tempo de Internação , Modelos Logísticos , Masculino , Morbidade , Pneumonia/epidemiologia , Pneumonia/etiologia , Pneumotórax/complicações , Pneumotórax/epidemiologia , Melhoria de Qualidade , Estudos Retrospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/epidemiologia , Fatores de Risco , Estatísticas não Paramétricas , Stents/estatística & dados numéricos , Taxa de Sobrevida , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/epidemiologia , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/epidemiologia , Ferimentos Penetrantes/cirurgia
20.
Am Surg ; 85(9): 1051-1055, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638523

RESUMO

This retrospective chart review demonstrates the relationship between bedside incentive spirometry (ICS) volumes and risk of pulmonary complications. Two hundred patients admitted for rib fractures between April and October 2016 were reviewed. The inclusion criteria were age 18-98 years, diagnosis of rib or sternal fractures, and no procedures requiring postoperative intubation within 48 hours of admission. The exclusion criteria were intubation before arrival, unable to participate in ICS, or previous tracheostomy. ICS volumes recorded in daily progress notes were collected. Of 200 charts reviewed, 154 met the inclusion criteria. In all, 25 endured at least one pulmonary complication. The average ICS on admission was 1355 cc. Patients who did not experience a complication had significantly higher admission ICS volumes than those who did (1441 ± 660 cc vs 920 ± 451 cc, P = 0.0003). They also achieved higher volumes at discharge (1705 ± 662 cc vs 1211 ± 453 cc, P = 0.006). The groups had similar demographics. An admission ICS volume <1 L was associated with 3.3× relative risk of pulmonary complication. Lower volumes were also associated with discharge to nonhome locations. Bedside ICS is a useful tool to identify patients at risk of pulmonary complications from rib fractures. Patients with admission ICS volume <1 L carry a higher risk of complication.


Assuntos
Pneumopatias/diagnóstico , Pneumopatias/etiologia , Testes Imediatos , Fraturas das Costelas/complicações , Espirometria , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco
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