Rib fracture features requiring CT for assessment of internal injuries in ED identified

5th April 2023

An analysis of rib fracture patients has identified the features associated with internal injury that warrant the use of a chest CT scan

An analysis by Korean researchers of patients admitted to an emergency department (ED) with a rib fracture diagnosed on chest radiography has identified important fracture characteristics indicative of significant intra-thoracic and intra-abdominal injuries that require assessment by chest computed tomography (CT).

The ribs are frequently affected by a blunt or penetrating injury to the thorax and within an ED, it is vital for the interpreting radiologist to not only identify the presence of rib injuries but also alert the clinician about organ-specific injury. A CT chest plays a major role for the in-vivo assessment of the body composition at the tissue/organ level and is the imaging modality of choice for accurate delineation of rib fractures and associated internal injuries. However, the main limitation associated with the use of CT scan is the ionising radiation patient burden. Consequently, identification of rib fracture features that could enable more appropriate use of a chest CT for such patients are warranted.

In the current study, the Korean team retrospectively analysed adult patients diagnosed with rib fracture due to blunt chest trauma that was diagnosed based on chest radiography and who underwent a chest CT examination. The researchers set the primary outcomes as intra-thoracic and intra-abdominal injuries that could be identified on a chest CT.

Rib fracture characteristics and need for a chest CT

A total of 401 patients with a mean age of 58 years (29.5% female) were included and of whom, 279 had any intra-thoracic or intra-abdominal injuries.

Overall, there was a higher number of rib fractures in those who sustained significant internal injuries (p < 0.001) and a higher level of bilateral fractures (p = 0.001).

In regression analysis, the number of fractures (adjusted odds ratio, aOR = 1.44, 95% CI 1.16 – 1.78), lateral fractures (aOR = 2.80) and posterior rib fractures (aOR = 3.18) were all independently associated with intra-thoracic and intra-abdominal injuries. Other factors also independently associated with such internal injury were the requirement of O₂ supplementation, mechanical ventilator use, requirement of transfusion, pelvic bone fracture and extremity fracture.

The authors concluded that among blunt trauma-induced rib fracture patients, posterior and lateral fractures, more than three fractures, the need for O₂ supplementation were the most important factors indicating the need for chest CT to identify intra-thoracic and intra-abdominal injuries in the emergency department.

Citation
Kim W et al. Characteristics of rib fracture patients who require chest computed tomography in the emergency department. BMC Emerg Med 2023

Intrathoracic bleeding after rib fracture similar for DOACs and vitamin K antagonists

7th January 2022

Intrathoracic bleeding in elderly patients seen in an ED after a rib fracture is not influenced by the type of anticoagulant taken

The incidence of intrathoracic bleeding seen in an emergency department (ED) after elderly patients sustain a rib fracture due to a fall, is similar whether patients have been prescribed a direct oral anticoagulant (DOAC) or a vitamin K antagonist (VKA) such as warfarin. This was the conclusion of a study undertaken by researchers from the Department of Emergency Medicine, Hospital of Merano, Verona, Italy.

Falls are the leading cause of ED presentations in people aged 60 years and older, accounting for almost 50% of all incident injury presentations. Thoracic trauma which is associated with blunt or penetrating injury is a major cause of hospitalisation throughout the world and accounts for 10–15% of all traumas with 23.9% of these patients experiencing one or two rib fractures.

The incidence of intrathoracic bleeding after rib fractures remains uncertain and the extent to which any bleeding is associated with the type of anticoagulation taken is also unclear. For the present study, the researchers wanted to examine whether preinjury treatment with either VKAs or DOACs had an effect on the incidence of complications, such as bleeding, among elderly patients who experienced blunt thoracic trauma after a fall.

They undertook a retrospective, observational study and included patients aged 75 years and older receiving oral anti-coagulants and who were found to have sustained at least one rib fracture due to a blunt chest trauma during their ED evaluation. Patients who trauma was caused by a car accident, who had a penetrating chest trauma, experienced severe changes in consciousness or who were haemodynamically unstable were excluded.

Eligible patients were then divided into two groups: those taking a DOAC and those prescribed a VKA and both clinical and demographic data was collected for all patients. Regression analysis was used to determine which, if any clinical of demographic factors were associated with the risk of bleeding.

Findings

Over a 2-year period, 342 patients with a median age of 84 years (gender not reported) met the eligibility criteria for inclusion, of whom, 38.9% were treated with DOACs. There were a total of 24 (7%) of patients who presented with intrathoracic bleeding of which 17 (5%) required a surgical intervention or died because of their bleeding.

Overall, 4.5% of patients taking a DOAC developed intra-thoracic bleeding after rib fractures compared to 8.6% of those taking a VKA (p = 0.19). In addition, 4.5% of DOAC and 4.3% of VKA patients required surgery or died due to their bleed (p = 0.98).

Using regression analysis, the authors reported that the most significant factors associated with a bleed were age (p = 0.045), the presence of chronic heart failure (p = 0.046), chronic renal failure (p = 0.012), the number of rib fractures (p < 0.001), a high injury severity score (p < 0.001) and dangerous trauma dynamics (p < 0.001). Furthermore, none of these factors were affected by the type of anticoagulant taken.

Commenting on these results, the authors suggested that DOACs and VKAs presented a comparable risk for intra-thoracic bleeding, concluding that the risk of bleeding in the elderly prescribed anticoagulants and sustaining a non-severe trauma appeared to be low.

Citation

Turcato G et al. Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients Emergency Care Journal 2021.