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Rib Fracture

Management and alternative to current treatment practices at a Level 1 Trauma Center
by

Nerlyne Desra

on 14 November 2012

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Transcript of Rib Fracture

Rib Fractures Ms. AP Ms. AP is a 33 y/o female level 1 trauma.
CC: injuries 2/2 MVC car vs. tree
Arrived via EMS on backboard
PMH: none
NKDA
Meds: None Timeline:
14:04 Call placed
14:24 EMS arrives
14:40 EMS leaves scene en route to DUMC
14:50 Trauma attending (Shapiro), Trauma SAR (Darrabie) arrive
14:53 Ortho consult arrive (Mayer)
14:53 Arrived
14:52 Lab drawn
14:57 peripheral IV in RAL
15:01 Log rolled
15:04 X ray of Chest, pelvis and forearm
15:06 Foley placed
15:10 Splint to Miami J
15:15: Peripheral IV in RH
15:20: Splint to RFA by Ortho
15:20 Secondary survey
15:25 CT scan of head, neck, chest, face and abdomen
16:15 Admitted to SICU
16:40 patient transported to 2200 ER Evaluation Current Recommended Therapy The current guideline for the management of rib and sternal fractures:

Imaging:
CXR should done with 10 minutes of the patient's arrival.

Analgesia for rib fractures:
Pain associated with rib fracture leads to respiratory insufficiency and sputum retention.

Pulmonary Support:
Volume expansion.
Advantages:
Same catheter for local anesthetics and opioids
Ease of placement
Duration of action
Use with bilateral fractures.

Disadvantages:
C/I in patients with coagulopathy.
DVT prophylaxis is a CI
Epidural can cause motor block limiting ambulation. Advantages:
Requires minimal attention from nursing
Can be used in coagulopathic patients.
DVT prophylaxis can be initiated and continued.
Surgeons can perform without a consult.
Showed decreased LOS.

Disadvantages:
May not be feasible with multiple rib fractures
Irreducible risk of pneumothorax Using an Epidural Using Continous Intercostal Nerve Block Other Possible Options: Paravertebral Nerve Block

Advantages:
Bedside
Regular epidural kit
One injection to place catheter
can be done on unconsious and patients with coagulopathies
No rib palpation required

Disadvantages:
Limited to patients with unilateral fractures


Intrapleural Nerve Block
Disadvantages:
Limited to patients with unilateral fractures
Studies have found better control with an epidural CXR:
Multiple bilateral rib fractures.
No evidence of pneumothorax

Pelvis XRay:
1. Comminuted, mildly displaced fracture involving the right acetabulumand extending into the right ischium.
2. Mild diastasis of the right sacroiliac joint.
3. Comminuted fracture involving the right ulna.

Femur Xray
Redemonstration of comminuted fracture of the right acetabulum extendinginto the right ischium with superior subluxation of the right femoralhead.

CT chest, abdomen, and pelvis with IV contrast,
2. Multiple acute (right) and chronic (left) bilateral rib fractures.
3. Comminuted right pelvic fracture primarily involving the acetabulumwith extension into the ischium. Diastases of the right sacroiliac joint.No free fluid within the pelvis to suggest bladder injury, however, if there remains clinical suspicion for bladder injury, CT cystogram is recommended.

CT spine
1. Comminuted, displaced fracture through the right acetabulum extendinginto the right ischium.
2. Mild diastasis of the right sacroiliac joint.
3. Multiple right-sided rib fractures, as above. Left-sided rib fracturesmay be subacute. by Nerlyne Dersravines, MS2 Secondary Survey Vitals:
GSC
AxO:
Physical Exam:
Chest -
Extremities - Labs PTT, PT/INR, T&S, BMP, UDS, ABC w/ diff, Shock Panel, UA and b-HCG
Noteable:
aPTT = 25.2, Cr = 1.3, WBC = 20.4
ABG: pH=7.28, pCO2 = 50, pO2 =39, base xs = -4
UA = Dark yellow, cloudy, 1+ ketone, 3+ bloods, 8 WBCs
UDS = + metamphethamine and benzodiazepine
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