1. Cracked Ribs and Sucking Holes
Carrie Valdez, MD
Trauma and Acute Care Surgeon, Covenant Hospital
cell

2. 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

3. 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

4. Cracked Ribs

5. 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

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

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

8. 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

9. Covenant Hospital Rib Fracture CPG

10. Covenant Hospital Rib Fracture CPG

11. 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

12. 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

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

14. 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

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

16. RibLoc System
Locking screws. Not dependent on bone quality

17. Our patient
Left rib fractures
#3-8

18. Our patient
Right rib fractures
#3-7

19. Our patient
Intraop

20. Our patient
Post op CXR

21. 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.”

22. 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

23. Sucking holes

24. What is a pneumothorax?

26. What is a TENSION pneumothorax?
Inspiration
Expiration

28. 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

29. Chest tube placement

30. Chest tube placed

31. Dazed and Confused…

34. Cracked Ribs and Sucking Holes
Carrie Valdez, MD
Trauma and Acute Care Surgeon, Coven-ant Hospital
cell