3.19 Chest trauma
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1 Introduction
Chest trauma in geriatric patients has vastly higher morbidity and mortality compared to younger patients and represents a challenging problem for treating physicians [1]. This chapter describes the fundamentals of systemic pain control, important local and regional anesthesia techniques, and the rare indications for operative intervention.
2 Epidemiology and etiology
The prevalence of geriatric rib fractures is increasing due to an aging population with increased life expectancy. Over the last six decades, life expectancy in western countries has increased from 68.2 years to 78.7 years [2, 3], and it has been estimated that the geriatric population will represent 25% of the US population by 2030 [4], including a significant increase in those older than 85 years.
This demographic change is predictably associated with an increasing incidence of rib fractures. Today, thoracic trauma accounts for 10–15% of all trauma admissions [5]. This number is expected to rise, since 11.3% of ground-level falls in patients older than 90 years are estimated to result in rib fractures [6].
As noted throughout this text, geriatric patients require a multidisciplinary approach to reduce mortality and achieve optimal outcomes [7]. In equally severe traumas, the mortality rate in geriatric patients is approximately five times higher compared with younger patients [1, 8, 9]. Studies demonstrate a correlation between mortality and the number of broken ribs, ie, “severity of trauma” represented as higher “injury severity scores” [10]. The higher mortality rates in geriatric patients can partly be explained by decreased physiological reserves and increased frailty but is likely also due to undertreatment of pain.
3 Diagnostics
During the last decade, computed tomographic (CT) scans have been increasingly used for chest trauma patients rather than conventional x-rays; this was prompted in part by the increased sensitivity of CT scans compared to x-rays in detecting rib fractures [11, 12]. Kea et al [13] showed that 18.1% of trauma patients had fractures detected by CT scans but missed on conventional x-rays. It is important to note that these fractures are usually minor and nondisplaced and do not change the treatment protocol, rendering routine CT scanning for rib fractures of little benefit [13–16].
Up to 2% of malignancies in the US, such as malignant tumors (ie, sarcomas, breast cancer or leukemia etc), are estimated to be caused by CT radiation [17, 18]. While most members of the geriatric population might not live long enough to suffer consequences from this radiation, the additional information gained typically does not lead to a change in treatment only adding to higher costs and the burdens of incidental findings (eg, lung nodules and false positives for pulmonary embolism [PE]) [19]. A CT scan should only be ordered in severe thoracic trauma, polytrauma, and in patients with suspicion of pneumothorax or PE. In most patients, diagnostic plain x-rays are sufficient. Ultrasound is also a fast and cost-effective tool to evaluate rib fractures, especially in cases where the fracture has been seen on x-ray and the clinical symptoms are severe [20]. At the same time ultrasound can be used to guide an intercostal nerve block if necessary ( Fig 3.19-1 ).
4 Therapeutic options
4.1 Pain treatment
When considering treatment options, physicians must account for specific issues unique to geriatric patients. The gold standard for patients suffering from broken ribs is nonoperative treatment with pain-adapted analgesia. Pain associated with rib fractures impairs respiratory function and increases pulmonary morbidity. Adequate pain control improves respiratory mechanics and decreases pulmonary complications such as atelectasis, pneumonia, and respiratory failure [8, 21, 22]. Unfortunately, geriatric chest trauma patients are often undertreated for pain, contributing to higher mortality rates [9, 23].
4.1.1 Intravenous analgesics
Intravenous analgesics are usually required for initial pain control, with conversion to oral medication after a few days (see chapter 1.12 Pain management). Primary systemic analgesic treatment is outlined according to the World Health Organization Treatment Guidelines on Pain [24] and can serve as the analgesic foundation for rib fracture patients. In order to provide adequate analgesia, it is necessary to routinely monitor the patient′s symptoms and response to medication. Geriatric patients in particular are often given inadequate analgesic treatment if not actively monitored. In practice, this can be achieved by routine pain assessment several times a day, using an appropriate and validated pain scale, eg, the Visual Analog Scale or Pain Assessment in Advanced Dementia scale for cognitively impaired patients (see chapter 1.12 Pain management). Analgesic medication dosing can be evaluated and adjusted as needed.
In general, patient-controlled analgesic systems are not appropriate for geriatric patients due to the high prevalence of dementia and delirium.
4.1.2 Intercostal nerve blocks
Intercostal nerve blocks can be an effective adjuvant treatment for rib fracture pain and can minimize the doses and side effects of systemic opioids. Intercostal nerve blocks can be done as a single shot or continuous infusion. In comparative studies, the continuous intercostal block has achieved better outcomes than epidural anesthesia in terms of pneumonia and ventilation-dependent respiratory failure, and the placement is typically less time-consuming [25–27]. The intercostal block is easy and safe to perform and has only few adverse effects. In clinical practice, this is an alternative for physicians who do not use epidural anesthesia in their daily routine. In many older patients, epidural anesthesia is contraindicated due to chronic anticoagulant, antiplatelet therapy, or other bleeding tendencies.
The author prefers an ultrasound-guided block which, in addition to the obvious advantages in obese patients, enables high-quality visualization of fractured ribs and can thereby optimize the position of the block. A continuous block is also easy to perform and, in the author′s experience, is ideally placed in patients with a high degree of pain on presentation, since these patients will otherwise require repeated injections. It is fairly easy to address two costal segments using only one skin puncture, by redirecting the needle while smoothly sliding from one subcostal space to the next. In this maneuver, sonographic guidance is also beneficial ( Fig 3.19-2 , Fig 3.19-3 ).
In the author′s experience, a series of single-shot blocks over the first 3 days has shown to be effective. Recurrent pain after depletion of the local anesthesia is usually considered to be less intense than the initial pain. The application of the blocks can easily be repeated.
In summary, intercostal nerve blockade can be considered equally effective as epidural anesthesia in treating pain and can be safely performed as either continuous administration or repeated injections [28]. It is simple to apply and has no significant neurological complications, nausea, vomiting, dizziness, or epidural bleeding as observed in other measures such as thoracic epidural injection or intravenous patient-controlled opioid analgesia. The disadvantage of this treatment is that multiple injections are necessary in patients with multiple fractures, and the effect of a single injection may only last 6–8 hours [29, 30]. Potential complications of this procedure include iatrogenic pneumothorax, hemothorax, bleeding, and infection [31].
4.1.3 Epidural anesthesia
Epidural anesthesia is considered an effective but advanced analgesic treatment option in patients with multiple rib fractures for whom intercostal nerve blockade is inadequate for pain relief and pulmonary function. Epidural analgesia can be done as a single-shot measure or as a continuous infusion, enabling pain relief for days due to administration of local anesthesia via an epidural catheter system.
In some studies, epidural anesthesia was reported to show superior outcomes across multiple domains when compared to intravenous opioid analgesics [32–34], including increased respiratory tidal volumes, reduced inflammatory response [35, 36], and even decreased mortality, but the results of other studies are conflicting. These studies report worse outcomes of epidural anesthesia in patients with pulmonary comorbidities compared with patients treated with intravenous opioids [37]. In these studies, some older frail patients experienced additional complications associated with epidural anesthesia including urinary retention, headache, decreased respiratory function, infection, epidural hematoma and neurological injuries [8, 38].
A metaanalysis of randomized controlled trials using epidural analgesia in patients with traumatic rib fractures by Carrier et al [39] did not show significant benefits of epidural analgesia in terms of mortality, length of intensive care unit (ICU) time, or overall hospital stay. The authors [39] point out that there may be a reduction in the duration of mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics.
Countering this is the evidence-based metaanalysis by Simon et al [40], who stated a level I recommendation for epidural anesthesia in patients with blunt chest trauma, including frail older adults. This metaanalysis maintained that epidural anesthesia significantly improves subjective pain perception and facilitates better pulmonary function tests as opposed to intravenous analgesia. Furthermore, this method of pain relief is associated with less respiratory depression, somnolence, and gastrointestinal symptoms than intravenous narcotics. Finally, epidural anaesthesia is considered to be a safer method in terms of complications, with low rates of permanent disability and negligible mortality. Epidural anesthesia requires the cooperation of a highly skilled anesthetist, as it is necessary to perform these blocks at a cervicothoracic spinal level, and can cause significant spinal injury if not performed properly. Epidural anesthesia is most strongly indicated in severe cases with multiple bilateral rib fractures; for less severe cases, the author generally prefers intercostal nerve blockade.
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