Margiotta Elysa, Wenger Isaac E, Henglein Jonathan, Kuo Yen-Hong, Boland Paul, Martella Nicholas, Betancourt-Ramirez Alejandro, Small Shannon F R
Department of Surgery, Northwell, New Hyde Park, New York; Department of Surgery at Zucker School of Medicine, Manhasset, New York.
Department of Surgery, Northwell, New Hyde Park, New York; Department of Surgery at Zucker School of Medicine, Manhasset, New York.
J Surg Res. 2025 Feb;306:1-9. doi: 10.1016/j.jss.2024.11.028. Epub 2024 Dec 30.
Patients with blunt chest wall injuries and rib fractures are known to have high rates of atelectasis, pneumonia, pulmonary contusion, and can develop acute respiratory distress syndrome. This can lead to ventilator requirement and dependence, deconditioning secondary to uncontrolled pain, and increased hospital length of stay (LOS). Many studies in the literature have developed triage algorithms in patients with rib fractures to guide disposition and management, and several institutions have gone on to describe their institution-specific management protocols to decrease complications related to traumatic rib fractures. The purpose of our study was to examine rates of in-hospital complications in patients with traumatic rib fractures before and after the implementation of a modified PIC (pain, inspiration, cough, designated as mPIC) protocol at our institution.
A retrospective review of patients presenting to our hospital with traumatic rib fractures were reviewed between 2019 and 2022, with inclusion of 820 patients. Information was collected on patients' demographics, mPIC score, components of their multimodal pain regimen, whether a local nerve block was performed, LOS, intubation rates, and early mobilization. Statistical analyses were performed and all results with a value of P value of <0.05 deemed statistically significant.
Our results show that implementation of our mPIC protocol was associated with dramatically reduced rates of intubation in patient with traumatic rib fractures (18.2% versus 3.0%, P < 0.001), regardless of patient's age, sex, race, or number of rib fractures. Furthermore, we also observed that patients with an Injury Severity Score (ISS) greater than 25 were less likely to be intubated after protocol implementation, (65.0% versus 16.7%, P < 0.001). We were able to see an associated significant decrease in overall LOS after implementation of the protocol, 5 d versus 4 d (P < 0.001); this association was seen even when stratified by race, age, number of rib fractures, sex, and ISS. We noted that with the addition of a multimodal pain regimen, other than the use of oxycodone, there was no associated overall difference in LOS preprotocol or postprotocol implementation. We also found that the implementation of early mobilization also correlated with a decreased overall LOS (P < 0.001).
Patients with traumatic rib fractures have many pulmonary complications that lead to increased use of hospital resources, increased hospital LOS and increased ventilator dependence. With implementation of our standardized mPIC protocol at our institution, we observed factors such as multimodal analgesia and early mobilization contributed to an associated statistically significant decrease in hospital LOS, even when stratified by age, sex, race, number of rib fractures, and moderate ISS or higher. We were also able to see an associated decrease in intubation rates among patients with traumatic rib fractures. Implementing such a protocol can, therefore, aid in diminishing the potential morbidities associated with traumatic rib fractures.
钝性胸壁损伤和肋骨骨折患者已知有较高的肺不张、肺炎、肺挫伤发生率，并可能发展为急性呼吸窘迫综合征。这可导致需要使用呼吸机并产生依赖，因疼痛控制不佳导致身体机能下降，以及住院时间延长。文献中的许多研究已制定了肋骨骨折患者的分诊算法以指导处置和管理，一些机构进而描述了其机构特定的管理方案以减少与创伤性肋骨骨折相关的并发症。我们研究的目的是检查在我们机构实施改良的PIC（疼痛、吸气、咳嗽，称为mPIC）方案前后创伤性肋骨骨折患者的院内并发症发生率。
对2019年至2022年间到我院就诊的创伤性肋骨骨折患者进行回顾性研究，纳入820例患者。收集了患者的人口统计学信息、mPIC评分、多模式疼痛治疗方案的组成部分、是否进行了局部神经阻滞、住院时间、插管率和早期活动情况。进行了统计分析，所有P值<0.05的结果被认为具有统计学意义。
我们的结果表明，无论患者的年龄、性别、种族或肋骨骨折数量如何，实施我们的mPIC方案与创伤性肋骨骨折患者插管率的显著降低相关（18.2%对3.0%，P<0.001）。此外，我们还观察到损伤严重程度评分（ISS）大于25的患者在方案实施后插管的可能性较小（65.0%对16.7%，P<0.001）。在实施该方案后，我们能够看到总体住院时间有显著相关的减少，从5天降至4天（P<0.001）；即使按种族、年龄、肋骨骨折数量、性别和ISS分层，这种相关性也很明显。我们注意到，除了使用羟考酮外，增加多模式疼痛治疗方案在方案实施前或实施后总体住院时间方面没有相关差异。我们还发现早期活动的实施也与总体住院时间的减少相关（P<0.001）。
创伤性肋骨骨折患者有许多肺部并发症，导致医院资源使用增加、住院时间延长和呼吸机依赖增加。在我们机构实施标准化的mPIC方案后，我们观察到多模式镇痛和早期活动等因素导致住院时间在统计学上显著减少，即使按年龄、性别、种族、肋骨骨折数量以及中度或更高的ISS分层也是如此。我们还能够看到创伤性肋骨骨折患者的插管率有所下降。因此，实施这样的方案有助于减少与创伤性肋骨骨折相关的潜在发病率。
