Cracked Ribs and Sucking Holes Carrie Valdez, MD Trauma and Acute Care Surgeon, Covenant Hospital carrievaldezmd@gmail.com 248-390-5864 cell

Pre-hospital 35F MVC- unrestrained, single passenger, head-on into tree EMS On scene, GCS 15 Vitals stable and normal Transferred to Critical Access Hospital Diagnosis Liver laceration, R acetabulum fx, scalp lac, rib fractures, R foot laceration Transfer to Covenant Hospital- Level 2 trauma center

Transfer Arrival: Labs: Imaging reviewed- appropriate care at OSH afebrile, BP 161/89, HR 81, O2 sat 96% on 4L NC, RR 28 Labs: H/H 13/39 EtOH 0 (per pt, drank 5 beers over 7 hours prior to MVA) Imaging reviewed- appropriate care at OSH Transferred to NTICU Dr. Valdez, critical care consultation Dr. Tucker, orthopedic consultation

Cracked Ribs

Rib fractures- how can they kill you? Respiratory failure Pneumothorax (rare) Pain and progressive loss of tidal volume Paradoxical movement of chest wall and loss of bellows Increased intrapulmonary shunt and V/Q mismatch Worsened by aggressive fluid resuscitation PNEUMONIA

Rib fractures- how can they kill you? Jones et al. Am J Surg. 2011; 202:598-604

Rib Fracture Pattern: Flail Chest Synergistic effect- increase age with morbidity and mortality N=277, 10 years, Bulger EM. J Trauma 48:1040- 1047, 2000. 7

Rib fractures - treatment Pain control Mechanical ventilation needed - Loss of tidal volume/minute ventilation due to pain - O2 failure due to shunting Surgical rib fixation Minimal fluid resuscitation

Covenant Hospital Rib Fracture CPG

Covenant Hospital Rib Fracture CPG

Surgical rib fixation - data Meta analysis of 11 studies (2 RCT): Significant decreases in: Mean ventilator days Mean ICU days Hospital days Risk of pneumonia Risk of septicemia Risk of mortality Rates of tracheostomy Chest deformity Slobogean et al. JACS 2013; 216:302

Surgical rib fixation- other considerations Marasco, Tanaka, and Bhatnagar all analyzed cost Found a $2,000-$14,000 decrease in medical costs in patients undergoing surgical fixation Despite cost of surgery, decreased ICU time and decreased complication rates made operative management less expensive

Which Ribs Should We Fix? Most effective for ribs 4-8 Consider ribs 3-9 Fix flail segments Fix displaced segments

Surgical rib fixation - timing Vital capacity < 55% of predicted “Take a deep breath” or “cough” Inability to talk in full sentences “I’m ok so long as I don’t move” Timing of procedure: EARLY

Hospital course HD2: HDS, no evidence of hemorrhage from liver laceration HD3: Dr. Tucker: ORIF R acetabulum Dr. Valdez: ORIF L ribs

RibLoc System Locking screws. Not dependent on bone quality

Our patient Left rib fractures #3-8

Our patient Right rib fractures #3-7

Our patient Intraop

Our patient Post op CXR

Post-op Rapidly improved respiratory mechanics Decreased narcotic use Transferred to rehab Follow up in trauma clinic “My ribs feel stable. I’m able to use my crutches.”

Take away points Rib fractures require appropriate pain control Rib fractures require pulmonary toilet Rib plating is a very useful adjunct for pain control Shortens length of mechanical ventilation Shortens length of stay Most important ribs are #4-8

Sucking holes

What is a pneumothorax?

What is a TENSION pneumothorax? Inspiration Expiration

What to do about it = CHEST TUBE Bedside procedure under local anesthetic Insertion of chest tube between 4th or 5th intercostal space Approximately nipple line Negative pressure suction chamber

Chest tube placement

Chest tube placed

Dazed and Confused…

Cracked Ribs and Sucking Holes Carrie Valdez, MD Trauma and Acute Care Surgeon, Coven-ant Hospital carrievaldezmd@gmail.com 248-390-5864 cell