Abstract
In this case report, we present 2 cases of flail chest in geriatric patients after severe blunt chest trauma, which were treated at the University Hospital Innsbruck (Level I Trauma Center and Tyrolean Geriatric Fracture Center) by a multidisciplinary team of physicians from anesthesia, intensive care, trauma surgery, and acute geriatrics. We want to point out the benefit of a multidisciplinary approach in geriatric patients with flail chest.
Chest injury with flail rib segments causes severe pain, difficulty in breathing, and mechanical pulmonary dysfunction leading to altered respiratory mechanics. Elderly patients who sustain blunt chest trauma with rib fractures have twice the mortality and thoracic morbidity of younger patients with similar injuries 1 . Additionally, there are different definitions for “flail chest” reported in the literature 2,3,4 . Anatomically, it is defined as the presence of at least 4 consecutive, unilateral, multiple fractured ribs. However, clinically, flail chest is diagnosed when an incompetent segment of chest wall is large enough to allow paradoxical motion of the chest wall with respiration 5 . In these types of severe injuries, conservative methods have been shown to be less effective at reducing the need for mechanical ventilation, decreasing pain, and allowing a faster recovery. Treatment of severe chest injuries may be changing from conservative methods to more recent interest in surgical stabilization. It is stated that a potential indication for operative rib fracture repair is the presence of flail chest 6 .
Two recent randomized trials with 37 and 40 patients, respectively, show that selected patients with flail chest may benefit from operative repair in both short- and long-term outcome. 7,8 Reported short-term benefits of open reduction and internal fixation of flail chest include accelerated restoration of pulmonary function, faster weaning, reduced morbidity, shorter stays in the intensive care unit (ICU), and earlier discharge from hospital. Long-term benefits include a decreased likelihood of clinically relevant long-term pain, respiratory dysfunction, and skeletal deformity. Despite the anticipated benefits after operative stabilization, the management of chest wall injuries is still a controversial topic as shown by a recent survey of 405 surgeons 9 .
In this report, we present 2 cases of flail chest in geriatric patients after severe blunt chest trauma, which were treated at the University Hospital Innsbruck (Level I Trauma Center and Tyrolean Geriatric Fracture Center) by a multidisciplinary team of physicians from anesthesia, intensive care, trauma surgery, and acute geriatrics. We want to point out the benefit of a multidisciplinary approach in geriatric patients with flail chest.
Case 1
An 87-year-old female, who was crushed against a wall by a bull, was transferred to our clinic after initial stabilization at a minor hospital in October 2010. She had broken ribs on both sides, I to X on the right with segmental fractures II to X and I to VIII on the left. Furthermore, a hematopneumothorax, hemorrhage and disruption of the lung, massive subcutaneous emphysema, laceration of the thoracic diaphragm without displacement of organs, liver rupture involving segment V + VII with involvement of the capsule, compression fractures of the third and eight thoracic vertebrae, and a hemorrhagic shock were diagnosed (Injury Severity Score [ISS] = 41). On arrival at the clinic, the patient was intubated and mechanically ventilated (Evita 4, Dräger; biphasic positive airway pressure [BIPAP]: level 19/10 mbar, time high 2.0/low 2.0 seconds, FiO2 = 1.0, PaO2 = 49 mm Hg, PaCO2 = 33 mm Hg) and put under analgosedation with morphine and midazolam. After primary stabilization at the emergency room, the patient received 4 chest tubes on the right side, one on the left, and recombinant factor VIIa (NovoSeven 6 mg, Novo Nordisk A/S Novo Alle, Bagsvaerd, Denmark) to stop hemorrhage of the lung. Afterward, the patient was transferred to the ICU. Four days after arrival and after multidisciplinary consultation with physicians from anesthesia, trauma surgery, intensive care, and acute geriatrics in the context of the Tyrolean Geriatric Fracture Center, the patient received operative stabilization of 3 ribs on the right side, as seen in Figure 1. After surgery, rapid improvement of the respiratory situation was noticed within hours. Proximate to the operative stabilization augmented ventilation with BIPAP was successful within 1 day (before stabilization: Evita 4, Dräger; BIPAP: level 18/10 mbar, time high 1.5/ low 2.5 seconds, FiO2 = 0.55, PaO2 = 87 mm Hg, PaCO2 = 46 mm Hg; after stabilization: BIPAP: level 18/8 mbar, time high 2.0/ low 2.0 seconds, FiO2 = 0.55, PaO2 = 121 mm Hg, PaCO2 = 40 mm Hg). Due to primary lack of vigilance and atelectasis of the lower lobe of the right lung requiring bronchoscopic therapy, weaning was delayed and extubation was not done until the 13th day. Stable hemodynamics requiring mild support with vasopressors (noradrenalin 0.15 µg/kg per min) did not change over time. The patient was discharged from the ICU after 21 days (spontaneous breathing: FiO2 = 0.21, PaO2 = 46 mm Hg, PaCO2 = 35 mm Hg). The patient was transferred back to the minor hospital near her hometown where she was discharged 2 weeks after admission. Unfortunately, we have no further information about the patients’ state of health afterward. The patient died 1 year after the accident.
Case 1, X-rays before and after stabilization, 3D-CT-scan on admission.
Case 2
A 78-year-old male was hit by a train while driving his car and arrived at the clinic in September 2011, with almost all ribs on both the sides fractured. Furthermore, a hemothorax on both sides, a pulmonary contusion, fractures of the transverse processes of the lumbar vertebrae I to IV on the right side and I on the left side, a hemoperitoneum after a ruptured liver cyst, and a metabolic acidosis were diagnosed (ISS = 32). On admission the patient was stable, awake, and noninvasive ventilated (Evita, Dräger: assisted spontaneous breathing [ASB]: PEEP = 8 mbar, pressure support = 4 mbar, FiO2 0.7, PaO2 = 96 mm Hg, PaCO2 = 61 mm Hg). Due to an increasing global respiratory insufficiency, the patient was intubated, mechanically ventilated, and analgosedated (morphine, midazolam) on the second day after admission. Initially conservative treatment of the rib fractures was attempted; however, the respiratory situation did not improve due to the malfunctioning respiratory mechanics. After several multidisciplinary consultations an operative repair of the flail chest was attempted since an improvement of the respiratory mechanics was anticipated. Operation was done 18 days after admission by means of plate osteosynthesis of the sixth and seventh rib on his right side. After this procedure, a sudden improvement of the respiratory mechanics, ventilation, and oxygenation ensued within 1 day (before stabilization: Evita 4, Dräger; proportional pressure support [PPS]: PEEP = 12 mbar, flow assist = 5 mbar, volume assist = 5 mbar, FiO2 = 0.5, PaO2 = 77 mm Hg; PaCO2 = 31 mm Hg; after stabilization: PPS: PEEP = 12 mbar, flow assist = 5 mbar, volume assist = 5 mbar, FiO2 = 0.5, PaO2 = 134 mm Hg, PaCO2 = 36 mm Hg). Eight days postoperatively, spontaneous ventilation and extubation was successfully possible. Stable hemodynamics with mild vasopressor support (noradrenalin 0.1 µg/kgper min) did not change over time. The patient could be discharged from the ICU 6 days after the extubation and was transferred to the ward (spontaneous breathing, FiO2 = 0.21, PaO2 = 62 mm Hg, PaCO2 = 38 mm Hg). During the further course the patient presented with adequate respiration although he had to stay at the ward for 1 month due to urinary tract infection resulting in acute renal failure. After the patient recovered, he could be discharged back home. During the ambulant follow-up examinations the patient showed no signs of impairment. The patient felt no thoracic pain and adequate breathing was possible during activities of daily living. One year after the accident no further controls were needed.
Discussion
On the basis of available literature, no formal recommendation can be made regarding which fixation technique is best 5 . The technique chosen depends on the experience of the individual surgeon. In our 2 cases stabilization was performed only on the right hemithorax and only 3 (case 1) or rather 2 of the broken ribs (case 2) were attended, using locking compression plates. In both the cases more massive damage was on the right thoracic side, and during the surgical treatment the thorax presented itself stable after stabilization of only 3 of 2 ribs, respectively.
Although the vast majority of rib fractures are appropriately managed nonoperatively, operative stabilization of flail chest should be considered for certain patients. 5 Operative treatment is increasingly recognized as a valid approach to improve pulmonary mechanics in selected patients with trauma. 6,7,10–12 Debate centers on patient selection and timing of operative treatment.
These 2 cases show that after a multidisciplinary approach and decision making for an operative stabilization both the patients benefit from the procedure by means of an improvement of the respiratory mechanics. Although there are no clear guidelines as to which patients need surgical stabilization, we want to emphasize the question, which selected geriatric patients with flail chest and respiratory failure (and thus requiring prolonged mechanical ventilation) will benefit from operative stabilization and who will not. This can and should only be decided in a multidisciplinary approach. We firmly believe that one medical professional cannot solve this question alone. For the patients’ benefit (improving chest stability and respiratory mechanics, faster weaning and shorter stay in the ICU) a multidisciplinary approach is mandatory.
In both the cases, the expert opinions of each specialist were considered by means of discussing the patients’ conditions from each point of view. It is not always an easy task to agreeing on the same decision, as was seen in these 2 cases, where 1 patient was not considered for a surgical approach until day 18 after admission. We still tend to treat such massive chest injuries conservatively because of our limited experience in such cases and the missing prospective randomized multicentric studies. Therefore, we emphasize that the establishment of such a multidisciplinary comanaged center like the Tyrolean Geriatric Fracture Center should be considered where professionals representing all necessary disciplines are routinely in charge of the injured elderly patients and their clinical needs 13 . However, in favor of a multidisciplinary approach we want to point out that the findings and conclusions of this case report require prospective evidence-based validation in a larger study population.
Footnotes
Acknowledgments
We gratefully thank Dr Devendra Agraharam, Department of Orthopedics & Trauma surgery, Ganga hospital, India, Dr Michael Blauth, head of the Department of Trauma Surgery, Medical University Innsbruck, for valued advice and helpful assistance as well as the Department of Radiology, Medical University Innsbruck, for providing the radiologic pictures.