Blunt chest trauma in the elderly: an expert practice review

Abstract

Trauma in the elderly (>65 years) is an increasingly common presentation to the ED. A fall from standing height is the most common mechanism after which such patients present, and rib fracture is the most common non-spinal fracture. Thoracic injury in patients aged over 65 is associated with significant morbidity and mortality. There are currently no universally applied guidelines for assessment, investigation and management of such patients. In this expert practice review, we discuss the evidence base and options for clinical management in this vulnerable patient group.

A survey of current practice in UK emergency department management of patients with blunt chest wall trauma not requiring admission to hospital

“…Research is needed to provide a patient and cost benefit for such additional services. Geriatric assessment for these patients in the ED was also suggested in this study and this agrees with one of the main conclusions in a recent review by Birse et al [18].…”

“…It is well-recognised that when blunt chest wall trauma is less severe, it is challenging to predict which patients are appropriate for discharge from the ED, as symptoms alone are insufficient to determine appropriate discharge [15,[22][23][24]. As concluded in a recent practice review, despite the prevalence and significance of chest wall injury in the elderly, there is currently no universally applied investigation strategy, risk score, or management guideline in use in either the UK or USA [18].…”

“…This advice may include guidance on analgesia, chest physiotherapy and return to activity [16,17]. A recent practice review concluded that structured national guidelines for the assessment and management of such patients that include appropriate rib fracture assessment tools may improve outcomes [18]. There is, to date, no universal agreement or supporting evidence for the content or format of a standardised guidance document.…”

Implementation of a chest injury pathway in the emergency department

“… 1 The importance of early detection and aggressive management of rib fracture has been well described in the literature, especially in the older population. 2 In the elderly, trauma to the thorax represents the second most common site of injury and mortality rates are two to five times higher compared with their younger counterparts. 3 Poor pain management leads to hypoventilation, pneumonia and respiratory failure and is the main cause of morbidity and mortality in these patients.…”

The clinical effectiveness of the STUMBL score for the management of ED patients with blunt chest trauma compared to clinical evaluation alone

“…As shown in Table 1 , the STUMBL (STUdy of the Management of BLunt chest wall trauma) score (also referred to as the Battle score) includes five predictors: age at attendance, number of rib fractures, chronic lung disease, use of pre-injury anticoagulants and oxygen saturation (SpO 2 ). This is the first score to introduce clinical variables, specifically chronic lung disease and anticoagulation, in contrast to other scores which have used anatomical variables and age alone [ 10 , 12 ]. A huge benefit of the STUMBL score is that these variables are all routinely measured in the ED.…”