Fixing Rib Fractures

Did you ever break a rib? 

As trauma nurses, first we look for signs that the rib punctured a lung - which would lead to a pneumothorax. Difficulty breathing after a rib injury may mean that your lung has collapsed and you need a chest tube.

However, difficulty breathing after a rib injury may be just because it hurts like Hell every time you breathe. Our intercostal muscles expand and contract our rib cage every time we inhale or exhale. 

Rib pain leads to shallow breathing. Shallow breathing leads to lung collapse or fluid accumulating in the lower lobes of the lungs, and that leads to pneumonia and other complications. 

We recently had a rib fracture specialist from Dr.John Mayberry Oregon Health Science University come and talk to the staff at our hospital. 

Here are a few of the takeaways:

• It is going to hurt - expect the pain to last for 3 to 4 months and it will take at least 50 days to get back to normal activity. 
• Toradol can help in the initial phase and Lidocaine patches can work too. 
• Incentive Spirometer, Cough and Deep Breathe ... but you already knew that. Respiratory, PT and OT is important to avoid complications. Get them out of bed and keep 'em moving. 
• Physiologic reserve - this drops after the age of 65 and means that you should admit patients with three or more rib fractures. Older than 65 and more than 6 fractured ribs is associated with a higher morbidity and mortality. Of course, with that mechanism, there is also the likelihood of multiple injuries.   

Why don't we internally fixate rib fractures like other broken bones? Mayberry is leading a study group on surgical and outpatient management of rib fractures. According to the OHSU website:

“Historically, physicians have been taught that nothing can be done to fix a rib fracture,” said John Mayberry, M.D., principal investigator of the study and associate professor of surgery in the OHSU School of Medicine. “My colleagues and I have long thought that wasn’t true, but we have yet to prove it. With this study, we hope to identify subsets of people who respond better to surgical repair than nonsurgical therapy, then develop a standard criteria for treatment.” 

Like clavicle fractures, rib fractures are one of those traumatic injuries we've always assumed healed best when left alone. We give patients tons of narcotics and tell them to cough and deep breathe. It takes a long time for these method to work.

  “Based on findings from our previous research, we are convinced that current, traditional nonsurgical management of rib fractures does not facilitate pain relief or a speedy return to normal activity. We believe new strategies, including a minimally invasive surgical method we’ve developed, will alleviate pain and reduce disability for individual participants,” said Mayberry, adding that patients in the United States disabled by acute rib fractures collectively lose approximately 58,000 years of productive work each year.

Nurse, Interrupted ...

A new study from down under finds that interrupted nurses are more likely to make errors. Seems like we could assume that was true but nice to see it quantified.  It doesn't seem to matter how much experience you have, if you get interrupted, you increase your chance of making a mistake in medication preparation, aseptic technique and other critical jobs. From Medscape:

"Experimental studies suggest that interruptions produce negative impacts on memory by requiring individuals to switch attention from one task to another," write Johanna I. Westbrook, PhD, from the University of Sydney in Sydney, Australia, and colleagues. "Returning to a disrupted task requires completion of the interrupting task and then regaining the context of the original task."  

For each interruption, there was a 12.1% increase in procedural failures and a 12.7% increase in clinical errors, with the association between interruptions and clinical errors independent of hospital and nurse characteristics. More than half (53.1%) of all administrations were interrupted (95% confidence interval [CI], 51.6% - 54.6%), and nearly three quarters of total drug administrations (74.4%; n = 3177) had at least 1 procedural failure (95% CI, 73.1% - 75.7%).  

Nurse experience did not protect against clinical errors and was actually associated with a higher rate of procedural failure. The frequency of the interruptions was associated with increased severity of the error. The estimated risk for a major error was 2.3% when there were no interruptions vs 4.7% when there were 4 interruptions (95% CI, 2.9% - 7.4%; P < .001). 

 "The converging evidence of the high rate of interruptions occurring during medication preparation and administration adds impetus to the need to develop and implement strategies to improve communication practices and to reduce unnecessary interruptions within ward environments. While it is clear that some interruptions are central to providing safe care, there is a need to better understand the reasons for such high interruption rates." 

 The question, however, is what can we do to reduce interruptions? In the emergency room especially, it's a difficult place for doctors and nurses to work without interruption. The patients are unstable and dynamic. Frequent updates are needed. So what do we do?

Questioning the Golden Hour for Ambulance Response

How fast should an ambulance go? In our rural area you are always at least 30 minutes from a hospital -- whether we go Code 3 in the Ambulance or put you on a helicopter. Still, we often drive sick patients to the hospital faster -- with lights and sirens blazing.

Of course, ambulances are not above traffic laws. We aren't supposed to fly through red lights or exceed the listed speed limit. Often running lights spook the other drivers into slowing to a crawl as they panic about getting off the road and out of the way. This is such a problem -- our lights and siren are such a hazard in some places -- that we turn them off to avoid making matters worse.

Moreover, Code 3 is dangerous. Accidents involving ambulances most often occur when responding with lights, siren and "turbo-diesel therapy." Medics are killed a rate three times higher than average workers mostly due to these accidents.

Yet time is muscle and speed saves lives right?

As reported this morning Slate Magazine, maybe not. New research indicates that the so called Golden Hour for the severely injured may not be as important as once thought. As Emergency doctors Pines and Meisel write:

Now a recent study in the Annals of Emergency Medicine casts further doubt to the concept of the golden hour for patients with severe injury. The authors studied more than 3,000 trauma patients—those with low blood pressures from bleeding, head injuries, and difficulty breathing—and looked at various time intervals after a 9-1-1 call. The times were compared with outcomes for the patients in the hospital. The result: shorter intervals did not appear to improve survival. These results are fascinating, in part because the principal question—how important is speed in the care of trauma patients before they get to the hospital?—has never been so elegantly explored. Previous efforts to measure the effect of ambulance time on survival have been plagued by the fundamental problem that medics may behave differently, like driving faster or spending more time working on patients, depending on the severity of the condition, making it impossible to tease out the effect of time on survival. While some of these biases remain, the authors of this study used sophisticated methods to account for many of these problems, allowing the reader to reasonably conclude that for ambulance care, a few minutes either way neither saves nor costs lives for patients with severe trauma.

 So what are we to think in all this? Do we need to "slow down with all due haste" as my dad used to say. Time does count when it comes to cells not getting oxygen. Time counts when a trauma center can prevent someone from bleeding out. However, we are increasingly able to do more in the field to buy time for transport.

I think application of Code 3 is required to come with some judgement -- not just as to the severity of the injury but also to whether seconds really count for this particular conditions.

Dr. Mullins Trauma Top Ten (part one)

Day two of the 21st Annual Northwest States Trauma Conference here in Sunriver and we get an early start counting down some of the latest research in trauma care. OHSU Trauma Surgery Eminence Dr. Richard Mullins held forth on the following hot topics.

#10
CT versus Laparotomy with penetrating wounds to the abdomen - The question: how do we best find injuries in the abdomen with patients presenting with penetrating abdominal wounds? Do we CT them? Open them up and look around or do serial, noninvasive physical exams.

The OAKLAND group found that CT was a great way find to triage abdominal injuries if "mandatory laparotomy signs" weren't present. Out of 306 patients, half of which got CT exams and only two false negatives were found. "That's pretty good," said Mullins, "but I think those guys probably missed a few more holes in the diaphragm." In any case, the Oakland group was dealing mostly with gunshot wounds and a lot of them.

The WESTERN just focused on stab wounds and defined the abdomen as below the costal margin. This group did wound exploration. Positive findings bought the patient 23 hours of serial physical exams. If they weren't showing signs of peritonitis, bleeding and were still hemodynamically stable, they got to go home.

The EASTERN trauma surgeons agree that serial physical exam is reliable IF there is a system to follow for the exams and a systematic way to record any changes. In otherwords, observation only works if you pay attention.

Mullins said he likes a delayed CT with oral contrast after six hours if there is still the possibility of damage to the bowel.

#9
 Using CT to determine which kidney injuries require intervention - One 5th of cardiac output is going to the renal system, so trauma can cause rapid exsanguination.  So who needs surgical intervention or angioembolization to control bleeding? Who will get better if you just observe them? Researchers found that injury scales are valid, correlating highly with outcomes. We also know now that there are three features of grade 3 and 4 renal injuries that require intervention to control bleeding. Most can be managed -- and managed earlier with angioembolization rather than later surgery and need for blood transfusions.

#8
 Surrogate and Doctor Expectations regarding ICU patient's long term Outcomes - This study was fascinating and sad. Surgeons managing a ICU patient on long term ventilation go to family members to ask for permission to put in a tracheostomy. Twenty percent of the patients died after the trach and of those that lived, only one out of 10 patients was doing well one year after discharge from the hospital to long term care. When asked of expected outcomes, neither the doctors, nor the surrogate decisionmakers were anywhere close to the reality of the outcomes. Worse, when the surrogates and family members were asked what had happened in the past year, 49 percent reported more stress in their lives and 84 percent had to quit their jobs to take care of the patient.

"We are looking at an enormous burden of families, and we need to communicate that accurately when we ask for persmission."

#7
Using procrit and other Erythropoiesis stimulating agents (ESAs) in patients with traumatic brain injuries - Usually ESAs are given to cancer patients to stimulate the growth of new red blood cells. However, this research looked at ten years of the drug's use in patient's with traumatic brain injuries. The death rate for those getting ESA was 8 percent compared to 24 percent in the other group. Strangely those getting the ESA had a lower hemoglobin on average than the control group.

#6
 Using Warm Fresh Whole Blood for trauma - Recent studies have shown that "old blood is bad blood" Mullins says. "Older than 29 days and you have two times the risk of infection. Yet the FDA says that blood can be kept for 42 days."

This study looked at the use of warm fresh whole blood in trauma patients in Iraq. While fresh whole blood in almost never given in the US these days due to screening restriction, in Iraq, pre-screening of military donors allowed 6,000 units of fresh whole blood to be given right after donation.  The results seem to be better trauma survival outcomes.

Why?

Even though the total red blood cells is the same, fresh blood has the plasma included.
"I think maybe the frozen plasma and platelets we give are not as good a coagulation cocktail as fresh warm blood," Mullin said. Studies in Japan have shown that trauma activates a coagulation cascade which consumes coagulation factors. Of the non-surviving trauma patients studied 87 percent had evidence of DIC. Fresh Warm Blood may stave off DIC in major trauma. "Some day blood donors will be part of the level one trauma team activation," Mullins concludes.

Read the Rest of the Top Ten HERE