Triage of Patients With Rib Fractures

Abstract

Background Most triage guidelines for blunt chest wall trauma focus on advanced age and multiple fractured ribs to indicate a high-risk patient population that should be admitted to an intensive care unit (ICU). Overly sensitive ICU admission criteria, however, may result in overutilization of resources. We revised our rib fracture triage guideline to de-emphasize age and number of rib fractures, hypothesizing that we could lower ICU admission rates without compromising outcomes. Methods Patients admitted to our level 1 trauma center over 9 months after the institution of the revised guideline (N = 248) were compared with those admitted over 6 months following the original guideline (N = 207) using Fisher’s exact and Wilcoxon-Mann-Whitney tests, as appropriate. Univariate followed by multivariate analyses were performed to determine risk factors for complications. Results The ICU admission rate significantly decreased from 73% to 63% ( P = .02) after the institution of the revised guideline, despite an increase in the patient’s age and injury acuity of the cohort. There was no significant difference in respiratory complications, unplanned ICU admission rates, and overall mortality. Poor incentive spirometer effort (750 mL or less) and dyspnea in the trauma bay were the strongest predictors of an adverse composite outcome and prolonged hospital length of stay. Discussion A revised rib fracture triage guideline with less emphasis on the patient’s age and the number of fractured ribs safely lowered ICU admission rates. Poor functional status rather than age and anatomy was the strongest predictor of complications and prolonged hospital stay.

Prospective validation of the Rib Injury Guidelines for traumatic rib fractures

“…Our guidelines may accurately minimalrisk rib fracture patients who are able to be safely discharged from the ED. Furthermore, the floor-to-ICU transfer rate for the revised guidelines by Leichtle et al 12 was approximately 6%, nearly four times greater than the rate of unplanned ICU admission among our RIG 2 patients, further demonstrating the relative safety and specificity of the RIG in guiding the management of rib fracture patients.…”

“…A total of 1,100 patients were identified, among whom 754 were in the PRE group and 346 were in the POST group. The mean ± SD age was 56 ± 19 years, 788 (71.6%) were male, and the median ISS was 14 (range, [10][11][12][13][14][15][16][17][18][19][20][21][22]. The most common mechanism of injury was motor vehicle collision (554 [50.4%]), 253 patients (23.0%) had ≥5 rib fractures, and 53 patients (4.8%) had a flail chest.…”

“…The revised guidelines set forth by Leichtle et al 12 are also limited in their applicability in that they only advise clinicians regarding ICU admission. On the other hand, our guidelines assist in decision making regarding triage to ICU or floor for high- to moderate-risk patients, and even discharge to home for minimal-risk patients.…”

“…6,11 Several rib fracture scoring and triage protocols have been introduced to identify high-risk patients and predict outcomes. 7,12,13 Other rib fracture scoring and triage systems commonly use advanced age, number of fractured ribs, and chest wall instability as relevant factors. [14][15][16] However, previous efforts were either lacking key patient history, physical examination findings, imaging results; were primarily focused on predicting outcomes rather than on guiding triage and management thereafter; or were only applicable to the elderly patient population.…”

“…[14][15][16] However, previous efforts were either lacking key patient history, physical examination findings, imaging results; were primarily focused on predicting outcomes rather than on guiding triage and management thereafter; or were only applicable to the elderly patient population. 12,16,17 One of the most straightforward scoring systems is the Rib Fracture Score, which takes into account only three variables: age, presence of bilateral fractures, and the total number of fractures. 18 However, subsequent studies showed poor predictive value for hospital and ICU lengths of stay, and discharge disposition, and poor explanatory ability for the variance in these outcomes, likely because of lack of in-depth fracture pattern information and deeper patient-level characteristics.…”