Physician-Led Thoracic Trauma Management

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1		Avinash Aujayeb	+ 1306 word(s)	1306	2021-12-17 05:03:15	\|
2	Done	Jason Zhu	Meta information modification	1306	2021-12-20 03:17:52	\|

This entry is adapted from the peer-reviewed paper 10.3390/jcm10245806

Falls cause 75% of trauma in patients above 65 years of age, and thoracic trauma is the second commonest injury; rib fractures are the most common thoracic injury. These patients have up to 12% mortality, with 31% developing pneumonias. There is wide variation in care.

trauma rib fractures thoracic trauma

1. Introduction

With local Caldicott approval, researchers collected data for a service evaluation on consecutive patients admitted with thoracic trauma to the respiratory unit between August 2020 and April 2021. An anonymized clinical record form was developed with Microsoft Excel 365. Continuous variables are presented as mean with ranges and categorical variables as percentages where appropriate. Simple descriptive statistics were performed. The size of all haemothoraces or pneumothoraces was assessed by a respiratory consultant.

2. Current Studies

A total of 119 patients were identified. The average age was 71. 1 years (range 23–97). 53 (44.5%) were male and 66 (55.5%) female. Of these patients, 19 patients did not have any pre-existing medical conditions, 85 patients were multi-morbid, most commonly presenting with ischemic heart disease (present in 65 patients), hypertension (present in 59 patients) and chronic kidney disease (present in 42 patients).

The mechanisms of injury were falls from standing (6554.6%), falls down stairs/bed or in the bath (18), ladders (4), cycling (12), assault (3), road accidents (8) and 9 others (for example off horses). Figure 1 shows the percentage of the mechanisms of injury. The average length of stay was 7.3 days (range 1–54). And 85 patients had more than one co-morbidity.

Figure 1. Percentage of the mechanisms of injury.

Locally, a trauma assessment is defined as the correct use of a trauma document, an assessment incorporating all aspects of a trauma pathway (primary and secondary surveys), or the patient undergoing a trauma computed tomogram (CT), dependent on the clinical assessment. Injury severity scores are not calculated routinely.

The average number of rib fractures for any patient was 3.6 (range 1–10). All had a pain review team, 22 erector spinae catheters were inserted with 2 paravertebral blocks. Additionally, 82 patients did not require oxygen, 1 required continuous positive airways pressure (CPAP) and 1 high flow nasal cannula (HFNC).

Figure 2 shows the length of stay by number of rib fractures (X axis) and no correlation was observed (Spearman’s correlation coefficient 0.23, Z score 2.53, 95% CI 0.545, 0.4047, with similar results if the outliers are removed).

Figure 2. Length of stay by number of rib fractures.

Isolated chest trauma was present only in 45 patients, 20 (17%) developed pneumonias and 16 (14%) deaths occurred within 30 days (1 heart failure and cancer progression, 2 COVID and 14 pneumonias), and all of these patients experienced falls from standing. The other injuries included sternal, scapular, pubic rami, vertebral, orbital, metatarsal, humerus and clavicular fractures as well as splenic, hepatic, adrenal and abdominal wall hematomas. Subdural hematomas were also present in three patients. All were managed on the respiratory unit, with specialist input from local orthopaedic, local surgical and regional neurosurgical teams. None of the patients required surgical intervention from general surgical and neurosurgical teams, and those (n = 4) who required orthopaedic surgery were managed pre-and post-operatively on the respiratory unit itself.

3. Discussion

The above study shows that high-level care for thoracic trauma in an elderly co-morbid population can be performed by respiratory physicians and an anaesthetist-led acute pain team. Mortality is high in the over 65 s and this is heavily influenced by a number of unique patient variables such as the frailty of the population being admitted and mechanism of injury ^[1]^[2]. This is a unique set up in the United Kingdom, and has not been previously reported.

Thoracic trauma is anecdotally treated by surgical, anaesthetic or orthopaedic teams ^[3]^[4]^[5]^[6]. The importance of the physiotherapy and acute pain teams cannot be underestimated with regard to the success of this set up. In the absence of adequately powered randomized controlled trials on intervention, versus observation in traumatic haemo-pneumothoraces ^[7], good clinical acumen and patient centered decision making allows for the safe and effective management of this clinical problem.

The report above simply documents the outcomes of current service but shows that researchers deal with an increasingly elderly population that is multi-morbid, and current study confirms that falls from standing (less than 2 m in height) are associated with significant trauma. Rurrent elderly patients are less likely to have a trauma assessment (the definition of which will vary in different hospitals) ^[1]. Rurrent cohort is too small to infer any meaningful statistics.

However, the 19% mortality in the above 65 age group needs further explanation (overall mortality 13%). Previously described overall mortality averages 10–12% ^[1], and if researchers excluded the patients who died of COVID-19, a major cause of excess death, rurrent mortality would be 10% overall, and 12% for the over 65 group. No patients below the age of 65 died, reflecting the fact that the above 65 group is frail and multi-morbid, often with irreversible, palliative pathology.

It has recently been proven in 585 patients (over the age of 65 years) with trauma from falls, that frailty, irrespective of its denominator and the age of the patient, directly correlates with survival at one year ^[2]. A frailty assessment could perhaps allow for a holistic approach and provide opportunities to improve outcomes. Rurrent service does not have this, and would perhaps benefit from embedding frailty assessments: however, there is no data to suggest that embedding this would improve outcomes- further research is required with control groups.

Manual searches for patients with rib fractures and trauma were performed on the admission for the ward. This is one of rurrent limitations, as well as the fact that researchers excluded patients managed on other wards. However, researchers still believe that the above-mentioned cohort is a representative sample. The main repository of data regarding trauma in the UK is the Trauma Audit and Research Network (TARN) ^[8]. TARN is the National Clinical Audit for traumatic injury and is the largest European Trauma Registry, holding data on >800,000 injured patients including >50,000 injured children. It is thus an extremely valuable source of information. However, TARN only accepts data from patients with traumatic injury with three or more overnight hospital stays or intensive care and/or high dependency care admission of any length or death due to injuries or if transfer to specialist major trauma centre is required. Unpublished data obtained for Northumbria Healthcare Foundation Trust spanning January to June 2021 reveals 347 patients, with an average length of stay of nine days, and average injury severity score (ISS) of 9. The vast majority of injuries (80%) were from falls less than 2 m in height. 107 out of 347 patients (31%) had a thoracic injury, and their length of stay was 7 days (same as above study), and the average ISS was nine. Again, falls from less than 2 m in height were the main causative factor. Overall, 88% of the thoracic injuries were isolated. Another limitation of rurrent study is that researchers do not have a control group (for example those without thoracic injuries) and the TARN data, presented above, is the best researchers currently have. Further work is planned in this respect.

An important point to discuss is the conservative versus interventional management of traumatic haemo-pneumothoraces. Traumatic pneumothoraces occur in 20% of all trauma patients ^[5]^[9]^[10]. A systematic search of the available literature did not reveal any completed randomised controlled trials pertaining to intervention’s in chest trauma. There is one such study ongoing in Canada, which is a randomized controlled study comparing patients with traumatic haemothorax managed by intercostal drainage or expectant management ^[11]. A further trial is planned in the United Kingdom, Conservative Management in Traumatic Pneumothoraces in the Emergency Department (CoMiT-ED). A Randomised Controlled Trial, to determine if traumatic pneumothoraces can be managed with simple observation ^[12]. Researchers have been invited to participate in this trial.

A significant educational drive is currently underway locally, regionally and nationally to increase awareness of the injury potential in the ‘elderly fallers’ ^[13]. This is a significant quality improvement project. Local radiological capacity will not sustain trauma-computed tomograms for all these patients, and the balance lies with good clinical acumen and a thorough assessment. Such a discussion is beyond the scope of this article, and Researchers propose to submit a follow up to this article once researchers have implemented new systems and collected outcomes.

References

Coary, R.; Skerritt, C.; Carey, A.; Rudd, S.; Shipway, D. New horizons in rib fracture management in the older adult. Age Ageing 2020, 49, 161–167.
Braude, P.; Carter, B.; Parry, F.; Ibitoye, S.; Rickard, F.; Walton, B.; Short, R.; Thompson, J.; Shipway, D. Predicting 1 year mortality after traumatic injury using the Clinical Frailty Scale. J. Am. Geriatr. Soc. 2021, 1–10.
Major Trauma: Assessment and Initial Management. Available online: https://www.nice.org.uk/guidance/ng39 (accessed on 21 October 2021).
Performance Comparison: Trauma Care. Available online: https://www.tarn.ac.uk/Content.aspx?ca=15 (accessed on 21 October 2021).
Thoracic Trauma. Available online: https://www.rcemlearning.co.uk/reference/thoracic-trauma/#1571736856360-e404677d-69f6 (accessed on 21 October 2021).
American College of Surgeons. Advanced Trauma Life Support (ATLS) Student Course Manual. Available online: https://learning.facs.org/system/files/ATLS%2010th%20Edition%20Student%20Manual_0.pdf (accessed on 21 October 2021).
JC: Conservative Management of Chest Trauma. St Emlyn’s. Available online: https://www.stemlynsblog.org/jc-conservative-management-of-chest-trauma-st-emlyns/ (accessed on 21 October 2021).
The Trama Audit and Research Network. Available online: https://www.tarn.ac.uk/ (accessed on 21 October 2021).
Walker, S.P.; Barratt, S.L.; Thompson, J.; Maskell, N.A. Conservative Management in Traumatic Pneumothoraces: An Observational Study. Chest 2018, 153, 946–953.
Gerhardy, B.C.; Liebenberg, P.; Simpson, G. Conservative management of traumatic pneumothoraces: A retrospective cohort study. Emerg. Med. Australas. 2021.
The Management of Traumatic Hemothoraces. Available online: https://www.centerwatch.com/clinical-trials/listings/203449/the-management-of-traumatic-hemothoraces/?&query=chest-trauma&rnk=7 (accessed on 21 October 2021).
Conservative Management in Traumatic Pneumothoraces in the Emergency Department (CoMiT-ED): A Randomised Controlled Trial. Available online: https://fundingawards.nihr.ac.uk/award/NIHR132889 (accessed on 21 October 2021).
Major Trauma in Older People. Available online: https://www.tarn.ac.uk/content/downloads/3793/Major%20Trauma%20in%20Older%20People%202017.pdf (accessed on 21 October 2021).

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Avinash Aujayeb

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1. Introduction

2. Current Studies

3. Discussion

References