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Midland Trauma Symposium: Delayed Pleural Collection After Blunt Chest Trauma

Midland Trauma Symposium: Delayed Pleural Collection After Blunt Chest Trauma. Miss Kate Martin FRACS General and Trauma Surgeon Alfred Hospital, Melbourne. Overview. Epidemiology of rib fractures Morbidity associated with rib fractures Pathophysiology Incidence of delayed HTHx

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Midland Trauma Symposium: Delayed Pleural Collection After Blunt Chest Trauma

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  1. Midland Trauma Symposium:Delayed Pleural Collection After Blunt Chest Trauma Miss Kate Martin FRACS General and Trauma Surgeon Alfred Hospital, Melbourne.

  2. Overview • Epidemiology of rib fractures • Morbidity associated with rib fractures • Pathophysiology • Incidence of delayed HTHx • Risk-Factors • Management

  3. Epidemiology of Rib Fractures • Incidence varies depending on patient population: • North America (NTDB) 2016: 10% ≥1 rib # • Major trauma only: 21-39% • Alfred: • All patients admitted into Trauma Service: 21% ≥1 rib # • Mechanism: • Motor vehicle-related trauma: 57-79% • Fall from standing: 16-23% • Mortality: • 2.5-22% for patients with ≥1 rib #

  4. Associated Injuries • Rib fractures occur in isolation in only 6-13% patients • PTHx, HTHx, H-PTHx: 32-72% • Pulmonary contusions: 17-26% • Flail chest wall injury: • ≥3 sequential ribs, fractured in ≥2 places each • Incidence (Alfred): • 2% of all trauma admissions • 10% of all patients ≥1 rib # • Extra-thoracic injury: • Head injury: 28-70% • Upper limb: 46-58% • Spine: 36% • Pelvis: 18% • Spleen: 7% • Liver: 5%

  5. Morbidity Associated with Rib Fracture • Complication rates: • 13-45% patients • Higher rate in patients >65 years • Types of complications: • Atelectasis and pneumonia • Respiratory failure • Aspiration • PE • Retained HTHx • Delayed pleural effusion (usually blood stained) • Empyema • (ARDS)

  6. Pathophysiology of Delayed Pleural Effusion • Range from serous transudate to frank blood • Most commonly caused by intercostal artery injury associated with displaced rib fractures: • Intercostal muscle and neurovascular injury • Fracture fragments are mobile: dislodge injured vessels • Inflammation associated with tissue injury and subsequent repair • Less common causes: • Diaphragm injury (including phrenic artery) • Great vessel injury • Iatrogenic

  7. Incidence of Delayed Pleural Effusion 12.2% 10.9% Ann Surg 2015. 262:1115-1122 13.5% CMAJ Open 5(2) 2017. Eur J Trauma Emerg Surg 2018.

  8. Risk Factors for Delayed Pleural Effusion • Number of fractured ribs: • ≥3 fractured ribs • Displacement of fractured ribs: • Displacement by at least half the width of the rib • Increasing age: • ≥65 years old Emond M et al. CMAJ Open. 2017. 5(2) Chien C et al. Scan J Trauma, Res Emerg Med. 2017. 25:19 Emond M et al. Ann Surg 2015. 262:1115-1122

  9. Risk Factors for Delayed Pleural Effusion CMAJ Open 5(2) 2017.

  10. Quebec Clinical Prediction Rule for Delayed HTHx • Patients ≥16 years with minor thoracic injury • Tool: • Age ≥70 years 2 points • Fractures high to mid rib regions (ribs 3-9) 2 points • Age 45-69 years 1 point • ≥3 rib fractures 1 point • Maximum score: 5 • High risk: 4-5 Sens 34% Spec 91% • Moderate risk: 2-3 Sens 76% Spec 65% • Low risk: 1 • 1 in 3 patients in high-risk group developed delayed HTHx

  11. Clinical Sequalae • Mild dyspnoea- often hard to differentiate from that caused by pain associated with rib fractures • More significant dyspnea- as ventilation is restricted • Associated pneumonia- particularly if there is restriction to lower lobe ventilation • Empyema- fluid acts as nidus for micro-organisms that have often already colonized a poorly ventilated lower lobe Often patients present to outpatients essentially asymptomatic!

  12. Management of Delayed Pleural Effusion • Expectant: • Minimal or no symptoms • Estimated volume <300ml J Trauma. 2012. 72:11-24 J Trauma. 2018. 84:454-458

  13. Management of Delayed Pleural Effusion • Drainage: • Symptomatic patients • Estimated volume >300ml • Intercostal catheter or pigtail drain • Adjuncts: • Analgesia • Mobility, chest physiotherapy • Nutrition • Oral hygiene • Optimisation of co-morbidities • Duration: • As shortest time as possible • CXR resolution

  14. Summary…. • Rib fractures are common and even ‘minor’ injuries can result in significant morbidity • Delayed pleural effusion is a recognised complication of chest wall injury • Incidence is possibly underestimated • Advanced age, multiple rib fractures and displaced rib fractures are recognised risk factors • Clinical presentation is variable • Management is determined by symptoms and signs, as well as volume and comorbidities • Management does not have to be a big tube…

  15. Thank-you! • ka.martin@alfred.or.au

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