Makindo Medical Notes

Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina |Rib Fracture Score

Calculate the RFS Rib fracture score

• There is a 10-15% incidence of rib fractures in patients undergoing blunt mechanism trauma (87% ICU trauma pts at BSUH in last 6 months). Risk factors for poor outcome include >3 rib fractured, age >65 and chest infection.
• A 2015 audit of rib fractures on ICU there were 52 patients, of which 43 sustained >3 ribs fractured. To identify patients at risk early the chest trauma pathway uses the Rib Fracture Score (RFS) which is calculated during assessment in ED (see table 1). The aim is for early analgesia, physiotherapy and critical care as appropriate (see fig 1).
• As part of this is an analgesic ladder (fig 2) which is to be escalated to achieve adequate analgesia with emphasis on use of regional analgesia early (including serratus anterior catheters).

Rib fracture score=(breaks × sides) + age factor

• ‘Breaks’ is the total number of fractures to the ribs and not the number of ribs fractured, e.g. 2 fractures in 1 rib scores 2.
• For ‘sides’, unilateral fractures scores 1 and bilateral 2.
• Age is factored with different age groups scoring between 0 and 4.

Regional Anaesthesia

Patient can be pre-assesed using the Criteria for referral for regional anaesthesia for rib fractures. Referral to the on-call anaesthetist for consideration of regional anaesthesia should be made when:

• Age <65 and ≥4 fractured ribs
• Age ≥65 and ≥3 fractured ribs
• Presence of a flair segment

Uncontrolled pain not responding to conventional analgesia or unacceptable side effects from systemic analgesia and/or worsening respiratory function (this includes patients in whom the co-morbidities preclude systemic opiates). Any catheter based technique (epidural/paravertebral block/serratus anterior block/erector spinae plane block) should be conducted in theatre with strict asepsis by an anaesthetist of any grade competent in the technique, with an anaesthetic assistant as per AAGBI recommendations.