Trauma toracico: indici predittivi il ricovero

in terapia intensiva.

Ilaria Bossi

Dipartimento di Medicina d’Urgenza

Ospedale S. Anna Como

Congresso AcEMC

7 Maggio 2015

•Blunt chest wall trauma accounts for over 10% of all trauma patients presenting to ED worldwide.

•Research has highlighted a mortality ranging 4 to 20%.

(Zeigler DW et al. The morbidity and mortality of rib fractures. J Trauma 1994;37:975-9)

Blunt

chest

wall

trauma.

Major injury

Middle injury

Minor injury

Surgery

Intensive care

Intensive care

Emergency or

surgical ward

Discharge and

follow-up

Surgery

•No current guidelines exist to assist in the management of this patient group unless the patient has severe, immediate life-threatening injuries.

(Battle et al. Injury.Int J. Care Injured 2012; 43: 8-17)

•Blunt chest wall trauma patients commonly

present to ED with no respiratory difficulties,

but develops respiratory complications

approximately 48-72 h later.(Alexander et al. The American Surgeon 2000;66:854-7)

•Clinical symptoms are not considered an

accurate predictor of outcome following non-

life threatening blunt chest wall trauma.(Dubinsky et al. Am J of Em Med 1997;15:240-3)

“Identify risk factors for mortality

in order to assist in the

identification of the high risk

patient and facilitate decisions

regarding the required

appropriate level of care”

2012-2015

Age > 18 years

�More than 3 rib fractures

�Lung contusion

�Pneumothorax

�Sternal fracture

Admission to Hospital (Emergency Ward)

Inclusion criteria

Exclusion criteria

•Need for immediate intubation and

mechanical ventilation

•Need for pneumothorax drenage

•Severe traumatic injury other than

blunt chest wall trauma

Standardized therapeutic

program

•Posture at 45 ° or more

•Cycle of positive airway pressure(by CPAP o by blowing through a tube in a bottle with 8 cm of water)

•Patient-controlled analgesia by tapentadol 200 mg/day or Fentanyl transcutaneous 50 mg

23 parameters 140 pz.

• AGE

• Charlson COMORBIDITY index

• COMORBIDITY

• CHEST WALL SCORE

• INJURY SCORE

• Fi02

• SP02

• P/F

• LACTATES

• BE

• PaC02

• NUM RIBS FRACTURES

• NUMBER CHEST CONTUSION

• PNX

• ABDOMINAL INJURY

• HEAD INJURY

• FRACTURES WITH IMMOBILISATION

• BONE INJURY

• BACINO INJURY

• PRE INJURY ANTICOAGULANTS

• SPINE XR

• VENT o PEEP

• ADMISSION TO ICU

• DEATH

AGE

Age N° Case

Age 20-40 15

Age 41-60 37

Age 61-70 32

Age 71-95 56

Max 95

Min 23

Media 63,6825

Mediana 68

Dev. Standard17,2737

Score N° Case

Score 0-2 59

Score 3-5 66

Score 6-7 13

Score 8-9 2

CHARLSON COMORBIDITY INDEX

Max 9

Min 0

Media 2,97

Mediana 3,00

Dev. Standard 2,04

CHEST WALL SCORE

Score N° Case

Sc.2-3 27

Sc.4-5 74

Sc.6-8 39

Max 8

Min 2

Media 4,76

Mediana 5,00

Dev. Standard 1,60

INJURY SCORE

Score N° Case

Sc.4-10 40

Sc.11-20 59

Sc.21-30 31

Sc.31-41 10

Max 41

Min 4

Media 15,81

Mediana 16,00

Dev. Standard 7,39

Num. Fractures

NUM RIBS FRATCURES

Score N° Case

0 7

1-2 21

3-4 52

5-7 41

8-11 13

>11 1

PNEUMOTHORAX

PNX Num

Pnx. 48

No 92

FRACTURES WITH IMMOBILIZATION

Immobiliz.N°

Imm. 24

No 116

ADMISSION TO ICU vers. DEATH

0

20

40

60

80

100

120

140

1 2No ICU N°130 Death N°2 --- ICU N°10 Death N°0

1,43%

Results

Fracture with immobilization(p = 0.0002; OR = 20.346

IC 95% 4.083 - 101.392)

Injury score(p = 0.0018; OR = 1.173

IC 95% 1.061 - 1.296)

Pain-control

PostureCycle of positive

airway pressure

Atelectasis

Lung Infections

Andrea Bellone

Francesca Cantaluppi

Massimo Guanziroli

Paolo Pina

Annamaria Bianchi

Massimiliano Etteri

Giovanni Casazza