A quiet chest: an injury whose severity is not yet visible

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Not clinically reviewed. No clinician has signed this scenario.

• Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48(6):1040-6; discussion 1046-7. Retrospective cohort of all 277 patients aged 65 or over with rib fractures admitted to a Level I trauma center over 10 years, against a control group of 187 randomly selected patients aged 18 to 64 admitted over the same period. The groups had a similar mean number of rib fractures (3.6 elderly vs 4.0 young), mean chest Abbreviated Injury Score (3.0 vs 3.0) and mean Injury Severity Score (20.7 vs 21.4), but mean ventilator days (4.3 vs 3.1), intensive care days (6.1 vs 4.0) and length of stay (15.4 vs 10.7 days) were all longer in the elderly. Pneumonia occurred in 31% of elderly versus 17% of young (p<0.01) and mortality was 22% versus 10% (p<0.01). Mortality and pneumonia rates increased as the number of rib fractures increased, with an odds ratio for death of 1.19 and for pneumonia of 1.16 per additional rib fracture (p<0.001); the conclusion states that for each additional rib fracture in the elderly mortality increases by 19% and the risk of pneumonia by 27%, which does not match the 1.16 reported in the results. Epidural analgesia in the elderly staying more than 2 days was associated with 10% mortality versus 16% without (p=0.28). The authors call for prospective study of epidural analgesia in this population.
• Bergeron E, Lavoie A, Clas D, Moore L, Ratte S, Tetreault S, Lemaire J, Martin M. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478-85. Consecutive adult blunt trauma admissions with rib fractures to a tertiary care trauma centre, April 1993 to March 2000, extracted from the trauma registry. Among 4,325 blunt trauma admissions there were 405 (9.4%) with rib fractures, of whom 113 were aged 65 or over; Injury Severity Score was 16 or above in 54.8%, mean hospital stay 26.8 ± 43.7 days, and 28.6% required mechanical ventilation. Mortality (19.5% vs 9.3%; p<0.05), comorbidity (61.1% vs 8.6%; p<0.0001) and falls as mechanism (14.6% vs 0.7%; p<0.0001) were higher in those aged 65 or over despite significantly lower Injury Severity Score (p=0.031), higher Glasgow Coma Scale score (p=0.0003) and higher Revised Trauma Score (p<0.0001). After adjusting for severity, comorbidity and multiple rib fractures, patients aged 65 or over had five times the odds of dying compared with those under 65.
• Duch P, Møller MH. Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials. Acta Anaesthesiol Scand. 2015;59(6):698-709. Systematic review with meta-analysis and trial sequential analysis of randomised controlled trials comparing continuous epidural analgesia with other analgesic interventions in traumatic rib fractures. Six trials totalling 223 patients were included and all were judged as having a high risk of bias. There was no statistically significant difference in mortality (RR 2.18, 95% CI 0.21-22.42; p=0.51; I2=0%), duration of mechanical ventilation (MD -7.53, 95% CI -16.32 to 1.26; p=0.09; I2=91%) or pneumonia (RR 0.49, 95% CI 0.19-1.25; p=0.13; I2=0%); subgroup, sensitivity and trial sequential analyses confirmed the results. The authors conclude that the quality and quantity of evidence is low and that there is no firm evidence of benefit or harm.