Pan London Rib Injury Toolkit
Blunt Chest Injury (BCI) affects up to one in four of all major trauma patients. Rib fractures are common in blunt chest injury and are associated with significant pain, respiratory complications and prolonged hospital stays. Management of traumatic rib fractures should therefore focus on early assessment of risk, timely effective analgesia and targeted rehabilitation.
This short animation provides an overview of the key priorities for managing Blunt Chest Wall Injuries:
Aims of the rib injury toolkit
Pathways of care for patients with BCI have the potential to improve outcomes (Baker et al). The overall aim of this toolkit is to provide a set of resources to standardise and optimise rib fracture management across the London Major Trauma System (LMTS). This toolkit does not mandate content for local rib injury guidance, but rather it provides evidence based resources, expert knowledge and effective examples to help trauma practitioners enhance their skills in the management of rib injured patients.
The resources presented within the toolkit have been developed or sourced by key stakeholders working across the London Major Trauma System*. Items will be added iteratively as workstreams mature and evidence increases.
*LMTS thanks Dr Ceri Battle for her expert consultation and collaboration in this toolkit development.
Key principles in the management of rib fractures
The following principles are considered best practice for management of rib fractures arising from blunt chest injury. When developing or updating rib fracture guidance Networks/MTCs/TUs should ensure that these principles are included:
1. Acute management of blunt chest injury/ rib fractures should follow standard algorithm-based care e.g. cABCDE to identify life threatening injuries.
2. Pathway: Patients should be managed on a rib fracture/ chest injury pathway that acknowledges evidence-based practice and suits the individual nature of the institution. See below for examples.
3. Risk score: Patients with rib fractures should be stratified for risk of complications/ management stream using a validated scoring system. Examples include the STUMBL score and Easter score.
4. Pain assessment: patients should have early and repeated pain assessment throughout their hospital stay. This should include a pain score at rest, a pain score on deep breathing/ coughing and ideally, assessment of neuropathic features.
5. Simple analgesia: patients should receive early multimodal analgesia. If there is evidence of neuropathic pain, anti-neuropathic drugs should be given.
6. Regional anaesthesia: multiple techniques are described for rib fracture analgesia. Current commonly cited examples include thoracic epidurals, paravertebrals, erector spinae plane and serratus anterior plane blocks. Units should select one, or a small selection of blocks, that can be performed by most anaesthetic staff most of the time, so that patients do not have to wait advanced analgesia. Anaesthetic staff should have regular training on these techniques.
7. Respiratory monitoring: patients’ respiratory status should be monitored with pulse oximetry and respiratory rate. Advanced monitoring e.g. with spirometry may be of value, including as part of the PIC score.
8. Respiratory support: patients should receive humidified oxygen targeting oxygen saturations within their normal range. Advanced respiratory support e.g. CPAP, non-invasive ventilation, high flow nasal cannulae and invasive ventilation should be available and used as indicated
9. Rehabilitation: simple patient led breathing exercises should be performed regularly. Early mobilisation and chest physiotherapy are key.
10. Patients should be managed on wards familiar with the care and management of blunt chest injuries.
Exemplar Rib Injury Pathways
Major Trauma centre example (courtesy of St Marys MTC)
Trauma Network/Trauma Unit example (courtesy of the NELETN)
