What is the treatment for a patient with an anterior chest wall injury, broken ribs, and hypotension?

Treatment for Anterior Chest Wall Injury with Broken Ribs and Hypotension

For patients with anterior chest wall injury, broken ribs, and hypotension, immediate resuscitation with fluid management and consideration for surgical stabilization of rib fractures (SSRF) is recommended, with careful monitoring in an ICU setting. 1

Initial Assessment and Stabilization

Hemodynamic Stabilization

• Address hypotension immediately with:
  • Intravenous fluid resuscitation
  • Blood products if significant hemorrhage is suspected
  • Vasopressors if needed after adequate volume resuscitation
• Note: Hemodynamic instability is a contraindication to immediate surgical stabilization but not to ICU admission 1

Imaging and Injury Assessment

• CT scan of the chest to evaluate:
  • Number of fractured ribs (≥6 ribs increases risk of adverse outcomes)
  • Displacement of fractures (severely displaced fractures increase risk)
  • Presence of flail chest (≥2 consecutive ribs each fractured in ≥2 places)
  • Anatomic distribution of fractures (anterior, lateral, posterior)
  • First rib fractures (associated with vascular injury risk) 2, 1
• Consider contrast-enhanced CT if high-energy mechanism or suspicion of intra-thoracic/intra-abdominal injury 2
• Evaluate for associated injuries, particularly with lower rib fractures which may indicate abdominal organ injury 2, 1

Treatment Algorithm

Pain Management

1. First-line: Regular intravenous acetaminophen (1 gram every 6 hours) 1
2. Add NSAIDs with caution if pain persists (consider patient comorbidities)
3. Opioids at lowest effective dose for shortest possible period (hydromorphone preferred over morphine) 1
4. Regional anesthesia techniques for moderate to severe pain:
   • Thoracic epidural
   • Paravertebral blocks
   • Erector spinae plane blocks
   • Serratus anterior plane blocks 1
5. Consider ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids 1

Respiratory Support

• Oxygen supplementation as needed
• Consider non-invasive ventilation (NIV) for patients with acute respiratory failure 1
• Mechanical ventilation for severe respiratory compromise or failure
• For patients on mechanical ventilation with flail chest, SSRF may reduce ventilation days 1, 2

Surgical Management

• Consider SSRF for:

  1. Flail chest with respiratory failure 2, 1
  2. ≥3 severely displaced rib fractures (displacement defined as <50% cross-sectional overlap) 2
  3. ≥5 consecutive rib fractures 3
  4. Patients failing non-operative management with persistent pain or respiratory compromise 4

• Early SSRF (≤48 hours) is associated with decreased ICU length of stay, overall hospital stay, ventilation days, and costs compared to delayed fixation 1

• Contraindications to SSRF:

  • Acute hemodynamic instability 1
  • Unstable spine fractures 4
  • Severe traumatic brain injury 4

Monitoring and ICU Care

ICU Admission Criteria

• Admit to ICU if any of the following:
  • Hypotension or hemodynamic instability
  • ≥3 rib fractures in patients >60 years
  • Flail chest
  • Significant respiratory compromise
  • Poor functional respiratory status (FVC <50% predicted) 1

Monitoring Parameters

• Continuous vital signs including blood pressure and oxygen saturation
• Serial arterial blood gases as needed
• Pain scores
• Respiratory parameters (respiratory rate, work of breathing)
• Chest X-rays to monitor for development of complications

Complications to Monitor For

• Pneumothorax and hemothorax
• Pulmonary contusion
• Pneumonia (higher risk with multiple rib fractures)
• Respiratory failure
• Vascular injuries (especially with first rib fractures) 2, 1
• Abdominal organ injuries (especially with lower rib fractures) 2

Follow-up Care

• Initial follow-up within 1-2 weeks of discharge for patients who underwent SSRF
• All patients should have follow-up within 2-3 weeks after discharge
• Evaluate pain control, respiratory function, functional status, and need for additional imaging 1

The RibScore can be used to predict adverse pulmonary outcomes based on 6 CT variables: ≥6 rib fractures, bilateral fractures, flail chest, ≥3 severely displaced fractures, first rib fracture, and at least 1 fracture in all 3 anatomic areas (anterior, lateral, posterior) 2, 1.