Rib fixation in a blunt trauma chest patient post-CPR: Navigating dual pathologies and poor chest physiology: Case report with review of literature

Abstract

Managing blunt trauma to the chest and associated rib fractures presents a complex challenge in poly-trauma patients, with considerable mortality and morbidity risks. While the global trend favours non-operative approaches, select centres advocate for surgical stabilization using Rib-specific plating systems. This becomes especially intricate post-cardiopulmonary resuscitation, yet it emerges as a pivotal intervention with significant implications for patient outcomes. We observed positive outcomes based on our experience in the systematic management of a flail chest case, incorporating critical care and chest wall stabilization. This comprehensive approach proved instrumental in restoring cardiopulmonary dynamics, optimizing oxygenation, reducing analgesic requirements, mitigating pneumonia incidence, facilitating mechanical ventilation, expediting weaning, supporting early recovery, and demonstrating cost-effectiveness. Despite these promising results, ongoing research is imperative to fine-tune patient selection criteria and refine indications for rib fixation. This approach holds the potential to minimise morbidity and mortality in thoracic injury cases, underscoring the need for continued exploration and validation of rib-specific plating systems in the evolving landscape of trauma care.

Introduction

A substantial segment of poly-trauma patients confronts elevated mortality risks, with thoracic injuries representing a significant contributor, responsible for approximately 25 % of fatalities [1]. Rib trauma, constituting 10 % of total trauma admissions, significantly contributes to the overall mortality and morbidity burden [2]. Each year, 12 % of patients with blunt trauma chest injuries succumb, with flail chest accounting for 15 % of these cases [3]. Notably, iatrogenic rib fractures (IRF) resulting from chest compressions during cardiopulmonary resuscitation (CPR) exhibit a higher in-hospital death rate (20.7 %) compared to traumatic rib fractures associated with chest wall instability [4]. The adverse effects of rib fractures on cardiac physiology, respiratory mechanics, and mechanical ventilation weaning techniques are well-documented [5].

Existing literature underscores the positive impact of chest wall stabilization (CWS) in reducing analgesic requirements, pneumonia incidence, ventilation days, and hospital stay duration. However, CWS has historically been contraindicated in cases involving hemodynamic instability, pulmonary contusion, and severe traumatic brain injury [6,7].

In this case report, we illuminate a scenario where CWS was performed in a patient presenting with a left flail chest, bilateral pulmonary contusion, and a post-cardiopulmonary resuscitation status. The successful outcome, leading to the patient's discharge after three weeks of treatment, highlights the potential efficacy of CWS in a challenging clinical context.

Case summary

In this case, a 45-year-old female patient presented to the emergency department with a history of being impaled between two trucks, exhibiting hemodynamic instability and paradoxical breathing. Immediate resuscitation was initiated following the Advanced Trauma Life Support (ATLS) protocol, including intubation and left-sided intercostal drainage (ICD) placement to address a hemopneumothorax with 700 ml of blood and air gush observed post-ICD placement (Fig. 1). Blood gas analysis indicated metabolic acidosis with respiratory acidosis. Whole-body contrast-enhanced CT scan revealed a left-sided flail segment in ribs 1–6, left-sided hemopneumothorax, bilateral pulmonary contusions, and a left-sided broncho-pleural fistula. At the same time, no traumatic brain, abdominal, or bony injuries were identified.

Fig. 1.

CT image after ICD placement.

Subsequently, the patient experienced a cardiac arrest upon transfer to the ICU, necessitating three cycles of cardiopulmonary resuscitation (CPR) for successful revival. Despite a challenging prognosis explained to the relatives due to trauma and the risk of hypoxic brain injury, resuscitation efforts continued with blood, blood products, and inotropic support. Upon improvement in the Glasgow Coma Scale (GCS) to E3VTM5, the patient underwent chest wall stabilization, specifically stabilising the 2nd to 6th ribs (Fig. 2). However, ongoing respiratory distress and failed weaning led to tracheostomy, despite chest wall stabilization. A gradual reduction in ionotropic requirements and successful weaning off the ventilator was achieved by post-injury day 14. The patient underwent bedside X rays with C arm (no films are available).

Fig. 2.

Shows surgical stabilization of 2nd-6th ribs.

The postoperative period was marked by an episode of generalised tonic-clonic seizure on day 8, prompting the initiation of levetiracetam. Neurological evaluations, including MRI brain and EEG, revealed Fazekas 1 leukoariosis and epileptiform discharges over the right hemisphere, respectively. At the time of discharge after three weeks of treatment, the patient demonstrated hemodynamic stability and the ability to perform incentive spirometry, reflecting positive outcomes amid the complex challenges posed by the severe thoracic trauma. The follow-up x ray was taken after 2 months of initial trauma (Fig. 3).

Fig. 3.

Postoperative image showing rib plating.

Discussion

The primary objective in managing rib fractures is to optimize lung function and address underlying thoracic injuries to prevent respiratory complications [3]. While global management typically leans towards non-operative strategies, such as analgesia, pulmonary hygiene, and ventilatory support, an increasing number of centres are adopting surgical stabilization methods [3]. Incorporating rib fracture stabilization adds dimension to management, with the surgical approach aiming to restore chest wall stability and mechanical integrity, while still considering conservative options [8].

Surgical stabilization of rib fractures has been well-established, particularly in patients with flail chest or multiple displaced fractures, as evidenced by various trials and meta-analyses. This intervention has demonstrated benefits in terms of reduced respiratory morbidity, shorter hospital stays, and lower mortality rates [6,9].

However, surgery is contraindicated in cases of cardiopulmonary resuscitation (CPR) or anoxic brain injury, where patients may not derive significant benefits. Prolonged ventilation due to traumatic brain injury or post-CPR status is also considered a factor against rib stabilization [10,11]. The literature does not support surgery for patients with pulmonary contusions, as these injuries are expected to worsen independently of chest wall injuries [12,13].

Despite these considerations, studies in the literature have advocated the role of rib fixation in post-cardiopulmonary arrest patients, suggesting potential improvements in respiratory functionality. Surgical stabilization has shown positive outcomes in ventilated and non-ventilated patients with flail chest, hemodynamically unstable patients, and those with multiple rib fractures without a flail injury [[12], [13], [14], [15], [16], [17]]. However no study in the literature has mentioned the advantage of rib fixation in blunt trauma chest patient who underwent CPR thus facing the challenge of poor chest physiology due to both pathologies (Table 1).

Table 1.

Studies in the literature mentioning the role of rib fixation in post CPR patients.

Author	Journal	Year	Country	Type of study	Number of subject	Number of ribs fixed	Outcome
Veelen et al. [14]	Frontiers in Surgery	2023	Egypt	Retrospective study	19	Mean number of ribs fixed - 5	Discharged
Comanici et al. [15]	Journal of Cardiac Surgery	2022	United kingdom	Case report	1	Right side – 1st to 7th Left side – 2nd to 7th	Discharged
Dorn et al. [16]	Interactive CardioVascular and Thoracic Surgery	2022	United kingdom	Retrospective study	13	Not mentioned	Primary outcome: total duration of ventilatory support, did not show there was no statistically significant difference Sx group: 13.3 days, No-Sx group:17 days Secondary outcome: Ventilation time after chest wall stabilization to extubation shows significant shorter time (6 days) in the Surgical group vs No-Sx group (17 days)
Claydon et al. [17]	Interactive Cardiovascular and Thoracic Surgery	2020	United kingdom	Case report	4	Median number - 6	Discharged
Drahos et al. [13]	Journal of Thoracic Disease	2019	Macon	Case report	1	Left 3rd-6th ribs	Discharged
Ananiadou et al. [12]	Interactive Cardiovascular and Thoracic Surgery	2010	Greece	Case report	1	Left 5th-6th ribs	Discharged

In the presented case, the patient had a flail chest due to trauma and a post-CPR status with unstable hemodynamics and a poor Glasgow Coma Scale (GCS) for nearly 10–12 hrs. The perceived salvageability was initially low, and the risk of ventilator-associated pneumonia could have further compromised the patient's condition if he survived. Despite these challenges, the trauma and critical care teams decided to proceed with rib fixation to salvage the young patient. Remarkably, the patient's respiratory parameters improved 48 hrs post-surgery, and he was successfully weaned within a week, eventually being discharged after three weeks.

This case report highlights the potential utility of rib fixation in patients with flail chest and concurrent cardiopulmonary arrest, underscoring the importance of carefully weighing risks and benefits in enhancing the management of chest trauma patients, given the substantial mortality rates associated with such injuries.

CRediT authorship contribution statement

Reecha Panghal: Methodology, Investigation, Data curation, Conceptualization. Alisha Chachra: Writing – original draft, Validation, Data curation, Conceptualization. Divakar Goyal: Writing – review & editing, Visualization, Validation, Supervision, Investigation, Formal analysis.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Divakar Goyal reports was provided by All India Institute of Medical Sciences, Bathinda.

Dr. Divakar Goyal reports a relationship with All India Institute of Medical Sciences, Bathinda that includes: employment.

If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.