The Southwestern Surgical Congress
Predicting outcome of patients with chest wall injury

Presented at the annual meeting of the Southwestern Surgical Congress, Rancho Palos Verdes, CA, March 27, 2012.
https://doi.org/10.1016/j.amjsurg.2012.05.015Get rights and content

Abstract

Background

Rib fractures occur in 10% of injured patients, are associated with morbidity and mortality, and frequently necessitate intensive care unit (ICU) care. A scoring system that identifies the risk for respiratory failure early in the evaluation process may allow early intervention to improve outcomes. The aim of this study was to test the hypothesis that a scoring system based on initial clinical findings can identify patients with rib fractures at greatest risk for morbidity and mortality.

Methods

A simple scoring system to stratify risk was developed and applied to patients through a retrospective trauma registry review. Points were assigned as follows: age < 45 years = 1 point, age 45 to 65 years = 2 points, age > 65 years = 3 points; <3 fractures = 1 point, 3 to 5 fractures = 2 points, >5 fractures = 3 points; no pulmonary contusion = 0 points, mild pulmonary contusion = 1 point, severe pulmonary contusion = 2 points, bilateral pulmonary contusion = 3 points; and bilateral rib fracture absent = 0 points, bilateral rib fracture absent present = 2 points. A review of trauma registry patients with rib fractures (June 2008 to February 2010) at a state-designated level 1 trauma center was performed. Data reviewed included age, number of fractures, bilateral injury, presence of pulmonary contusion, classification of the contusion, length of hospital stay, mechanical ventilation, ICU admission, and length of stay. The scoring system was retrospectively applied to 649 patients to determine validity.

Results

A score ≤ 7 indicated lower mortality (24 of 579 [4.2%]) compared with patients with scores > 7 (10 of 70 [14.3%]) (Fisher's 2-sided P = .0018). Patients with scores ≤ 6 were less likely to be admitted to an ICU (29.7%) compared with those with scores ≥ 7 (56.7%) (P < .0001). Patients with total scores < 7 were less likely to require intubation (20.6%) compared with those with scores ≥ 7 (40.0%) (P < .0001). Patients with scores ≤ 4 had shorter lengths of stay (36.0% <5 days) compared with those who had scores > 4 (59.7%) (P < .0001).

Conclusions

A simple scoring system predicts the likelihood that patients will require mechanical ventilation and prolonged courses of care. A score of 7 or 8 predicted increased risk for mortality, admission to the ICU, and intubation. A score > 5 predicted a longer length of stay and a longer period of ventilation. This scoring system may assist in the earlier implementation of treatment strategies such epidural anesthesia, ventilation, and operative fixation of fractures.

Section snippets

Methods

This study was performed at a busy, state-designated level 1 trauma center. After obtaining approval from the institutional review board, a simple scoring system to stratify risk for patients with rib fractures was developed on the basis of currently available literature (Table 1). The scoring system was specifically formulated to use clinical data available at the time of initial patient evaluation. The validity of the scoring system was tested by retrospectively applying the system to a large

Mortality

Patients with total scores ≤ 7 had a statistically significant lower mortality rate (24 of 579 [4.2%]) compared with patients with total scores > 7 (10 of 70 [14.3%]) (Fisher's 2-sided P = .0018).

ICU admission

Patients with a total scores ≤ 6 were less likely to be admitted to an ICU (29.7%) compared with patients with total scores ≥ 7 (56.7%) (P < .0001).

Mechanical ventilation

Patients with total scores < 7 were less likely to require intubation and mechanical ventilation (20.6%) compared with those with scores ≥ 7 (40.0%) (P <

Comments

Much of the respiratory insufficiency associated with chest wall injury is due to pain associated with rib fractures. Whether because of chest wall deformity or decreased respiratory effort in attempts to reduce pain with breathing, the loss of normal pulmonary function decreases gas exchange and the ability to clear secretions, increases atelectasis, and is associated with the development of pneumonia. Continued decline in respiratory effort and pulmonary function results in the need for

Conclusions

A scoring system can be used to predict which patients are more likely to require mechanical ventilation and require prolonged courses of care, as well as those with a higher mortality risk. Patients with total scores ≥ 7 are at greater risk for mortality, admission to an ICU, and mechanical ventilation. Patients with scores ≥ 5 are more likely to experience longer lengths of stay and mechanical ventilation. The use of this scoring system may help in the immediate identification of patients who

References (18)

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