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Rib Fracture Management in the Older Adult; an Opportunity for Multidisciplinary Working

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Rib Fracture Management in the Older Adult; an Opportunity for Multidisciplinary Working Subspecialty Section Rib fracture management in the older adult; an opportunity for multidisciplinary working Lauren Richardson and Shvaita Ralhan The elderly will soon make up the largest number of patients sustaining major trauma; a fall from standing height is their most common mechanism of injury1. Rib fractures are a common consequence of blunt chest trauma and are important to recognise and diagnose as complications can be fatal. They can be considered a surrogate for major trauma as up to 90% of patients will Lauren Richardson is an ST7 Registrar go on to have additional injuries identified2. The older in Geriatric and General Medicine working in the Thames Valley. Whilst adult presents a unique challenge. Their injuries are often undertaking a fellowship in Perioperative under-estimated and therefore under-triaged. Delays to Medicine she helped to develop the diagnosis are not uncommon3. Major Trauma Geriatric service at the John Radcliffe Hospital in Oxford. he mortality and thoracic deal with. Decisions regarding which team morbidity in the elderly as these patients should be admitted under can a result of rib fractures is therefore be contentious. Nationally, there is double that of their younger significant variation, and even in institutions counterparts. In elderly patients, such as ours where pathways do exist, Tfor each additional rib fracture, mortality conflicts often arise as to where the patient increases by 19% and the risk of pneumonia should be managed and by whom. increases by 27%4. It is therefore not surprising that older adults who sustain rib This article aims to address the key issues fractures have increased lengths of stay and that arise when managing older adults with more prolonged intensive care admissions5–7. rib fractures and highlights the importance of tailoring clinical care to their specific needs. Shvaita Ralhan trained in Geriatric and Elderly patients whose injuries are not General Internal Medicine in London, recognised at the front door are usually Imaging and is now a Consultant in Perioperative spread across a number of different bed Medicine at the John Radcliffe Hospital. bases within the hospital. They are often on A plain chest radiograph will only detect She is interested in major trauma in medical wards where staff have comparatively 50% of rib fractures8 whereas computerised older patients and has set up the Major limited experience in managing traumatic tomography (CT) is significantly more Trauma Geriatrics service in Oxford. injuries. Older adults who sustain rib sensitive and is therefore the recommended fractures are often frail and comorbid. Their imaging modality9. Due to underlying She is passionate about teaching, has injuries cause decompensation of their osteoporosis, the elderly can sustain life- completed a Masters in Clinical Education, medical problems and delirium which in turn threatening injuries following what can and runs the Perioperative Medicine leads to complex discharge planning; issues be perceived as minor insults. Therefore, fellowship programme in Oxford. that surgical teams do not feel best placed to as clinicians, we should have a very low 58 | JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk Subspecialty Section threshold for performing cross sectional Analgesia imaging if chest injuries are suspected; Risk factor Score particularly in this patient group. The Morbidity and mortality presence of flail chest is associated with from rib fractures occurs Age 1 Score 1 for each additional 10-year increase after the age of 10 significant mortality (15-17%)10; paradoxical as a result of respiratory movement of the flail segment during complications. Direct Number of rib fractures 3 Score 3 for each additional rib fracture inspiration restricts the underlying lung trauma, impaired gas tissue, increases the likelihood of lung exchange and pain- Chronic lung disease 5 contusion and leads to ineffective ventilation. induced hypoventilation predispose to atelectasis, Anticoagulant use pre-injury 4 retention of pulmonary Risk stratification Oxygen saturations 2 Score 2 per 5% reduction in oxygen secretions, pneumonia saturations; starting at 94% There are a number of risk stratification scores and respiratory failure. that have been validated for use in rib fractures. Adequate analgesia is Table 1: Battle Score. In our centre we use the Battle Score11 which therefore the cornerstone comprises a number of factors that are known of effective rib fracture to influence outcomes (Table 1). management. Final risk score Probability of developing complications The final score is then converted to a As a general rule, percentage risk of developing complications escalation of analgesia 0-10 13% (Table 2). Complications in this instance is guided by the risk 11-15 29% refers to mortality, morbidity (including stratification score all pulmonary complications), admission although in our 16-20 52% to intensive care and prolonged inpatient experience, individual admission (greater than 7 days). patient requirements 21-25 70% can vary hugely. Lower With a point given to each decade of life, scores are treated with 26-30 80% the elderly automatically score highly. For oral analgesia in the first 31+ 88% example, an 80-year-old with a background instance whereas the of asthma and atrial fibrillation who is taking highest scores should Table 2: Probability of complications. Apixaban will score 16 on the Battle Score be referred for specialist without having even sustained a fracture. pain team input and Additionally, this scoring system does not consideration of regional make any adjustment for patients with lower anaesthesia. Battle score Recommendation baseline saturations; such as those with Chronic Obstructive Pulmonary Disease Locally, patients are Conservative 0 -10 simple oral analgesia, may be safe for (COPD). grouped depending discharge home on their Battle Score Progressive 11-20 consider PCA Other validated scores include the Rib Score (Table 3). (RS), Rib Fracture Score (RFS) and the Chest Aggressive 21-30 PCA and consideration of regional anaesthesia Trauma Score (CTS). In a recent comparison It is vital that patients of these three scores12, the CTS was felt to be are able to cough and Emergent 31 or more urgent assessment for regional anaesthesia most useful in predicting outcomes in patients take a deep inspiration. over the age of 65. A score of six or more If pain is continuing to Table 3: Battle score and recommendations. was associated with an increased mortality, limit effective respiration increased length of stay and increased rates or engagement with of pneumonia. This scoring system puts less physiotherapy then analgesia must be up- Analgesia should therefore always be reviewed emphasis on patient specific characteristics titrated as a priority. Elderly patients with in a patient who is newly confused. but gives points for injury related factors cognitive impairment may not always be able to including the number of ribs fractured, articulate that they are in pain and so attention There are several factors that must be bilateral fractures and the presence of should be paid to non-verbal and observational taken into account when prescribing in the pulmonary contusions13. cues. These include autonomic changes, facial elderly. Non-steroidal anti-inflammatory expressions and drugs (NSAIDs) are often contra-indicated body language in the older adult due to pre-existing medical as well as conditions such as heart failure, renal failure inter-personal or risk of gastro-intestinal bleeding. Codeine “Morbidity and mortality from rib fractures interactions. and oral morphine are renally excreted and Tools such as should be used with extreme caution in renal occurs as a result of respiratory complications. The Abbey impairment due to the risk of accumulation. Direct trauma, impaired gas exchange and Pain Scale14 or Oxycodone is therefore preferred. With Visual Analogue all routes, opioids can cause hypotension, pain-induced hypoventilation predispose to Scales should sedation, falls and delirium. atelectasis, retention of pulmonary secretions, be considered. Alongside many The use of Patient Controlled Analgesia (PCA) pneumonia and respiratory failure. Adequate other causes, requires both cognitive ability and manual pain is also a dexterity. Patients who are confused, have analgesia is therefore the cornerstone of well-recognised concurrent upper limbs injuries or those with effective rib fracture management.” trigger for severe arthritis are likely to have difficulties delirium. and this must be taken into consideration. >> JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk | 59 Subspecialty Section Regional anaesthesia reduces the systemic Other considerations Rib fracture patients admitted under opioid burden which is particularly important the care of Trauma and Orthopaedics in the elderly who are more susceptible Chest physiotherapy is essential for all patients (in contrast to General Medicine or to side effects15. Conventional techniques with rib fractures18. Evidence also supports the Cardiothoracics) tend to be polytrauma to manage rib fractures include epidural use of humidified oxygen and saline nebulisers patients who have additional injuries. analgesia, paravertebral and interpleural to help with secretion clearance19. In patients This adds an extra layer of complexity to blocks. However, these their management. are relatively contra- In particular, indicated in those who are patients with spinal anti-coagulated16; which “Rib
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