Continuous serratus anterior plane block provides analgesia in multiple rib fractures: a case report / O bloqueio contínuo do plano serrátil anterior fornece analgesia em fraturas múltiplas de costelas: relato de caso

Abstract Thoracic trauma with rib fractures is a challenging condition due to the severe associated pain. Uncontrolled pain impairs breathing and an adequate pain control is necessary to provide comfort and to avoid further complications. Serratus Anterior Plane block is a procedure safe and easy to accomplish. The authors describe a case of thoracic trauma with rib fractures and respiratory compromise. Pain control was only achieved after performing a Serratus Anterior Plane block. The technique was done as described in the medical literature with placement of a catheter. Pain relief was achieved with a low concentration infusion of local anesthetic.

Resumo O trauma torácico com fraturas de costelas é uma condição desafiadora devido à dor intensa associada. O não controle da dor prejudica a respiração enquanto, o seu controle adequado é necessário para proporcionar conforto e evitar maiores complicações. O bloqueio do plano serrátil anterior é um procedimento seguro e fácil de fazer. Descrevemos um caso de trauma torácico com fraturas de costelas e comprometimento respiratório. O controle da dor só foi obtido após o bloqueio do plano serrátil anterior. A técnica foi aplicada conforme descrito na literatura médica, com a colocação de um cateter. O alívio da dor foi obtido com uma infusão de anestésico local em baixa concentração.

Phrenic Arterial Injury Presenting as Delayed Hemothorax Complicating Simple Rib Fracture

Delayed hemothorax after blunt torso injury is rare, but might be associated with significant morbidity and mortality. We present a case of delayed hemothorax bleeding from phrenic artery injury in a 24-year-old woman. The patient suffered from multiple rib fractures on the right side, a right hemopneumothorax, thoracic vertebral injury and a pelvic bone fracture after a fall from a fourth floor window. Delayed hemothorax associated with phrenic artery bleeding, caused by a stab injury from a fractured rib segment, was treated successfully by a minimally invasive thoracoscopic surgery. Here, we have shown that fracture of a lower rib or ribs might be accompanied by delayed massive hemothorax that can be rapidly identified and promptly managed by thoracoscopic means.

Trauma de tórax / Chest trauma

El traumatismo de tórax es una situación altamente desafiante en el manejo de urgencia. Requiere conocimientos de las complicaciones que pueden poner en riesgo vital al paciente en pocos minutos como de un adecuado manejo primario de las complicaciones que se pueden presentar en el mediano y largo plazo. De la mortalidad total del trauma, un 75 por ciento se debe a trauma torácico como causa primaria o como elemento contribuyente. Es por esto que el manejo de estas lesiones torácicas es esencial en el trabajo de urgencia. Un 80 por ciento de las lesiones torácicas pueden manejarse con maniobras no quirúrgicas, pero el 15 por ciento a 20 por ciento restante requerirá manejo quirúrgico, que es altamente desafiante, por lo complejas que pueden llegar a ser las lesiones de estructuras vitales presentes en el tórax. En la siguiente revisión mostramos el manejo de las lesiones más frecuentes en traumatismo torácico y las distintas indicaciones de toracotomías que se pueden presentar en los servicios de urgencia.

Thoracic trauma is an extremely challenging situation in the emergency room. Both ER physicians and surgeons should have knowledge of how to manage immediate life threatening injuries and the related complications that can present later. The primary cause or contributing element of seventy five percent of trauma related mortality is thoracic injury. Eighty percent of thoracic injuries can be managed non-surgically. The remaining 15 percent to 20 per cent will require challenging surgical procedures, due to the involvement of vital organs and vessels. In this review, we present the management of the most common trauma related thoracic injuries that can present in the ER and the different indications for thoracotomy.

rare cause of trauma in the elderly: Mobitz type-II second-degree atrioventricular block

Cardiac rhythm problems are frequently seen in the geriatric population, and they can experience trauma after syncope. A 78-year-old female was examined for thoracic trauma after falling. With a history of -blocker use, arterial blood pressure measured 60/30 mmHg and pulse rate was 30 bpm. Electrocardiogram showed a Mobitz type-II second-degree atrioventricular block. There was no response to atropine, so a transcutaneous external pacemaker and after that a transvenous pacemaker were applied. On the 4th day, the pacemaker was removed and the patient was discharged

Hérnia intercostal transdiafragmática após fratura espontânea de costelas secundária à crise de tosse / Transdiaphragmatic intercostal hernia after spontaneous rib fractures secondary to coughing fit

One case of transdiafragmatic intercostal hernia after intense coughing fit followed by rib fractures in patient with history of pneumonia is presented. He had a severe coughing fit, developed a right toracoabdominal hematoma and then a tumor that was gradually enlarging. Image exams confirmed the diagnosis. Treatment consisted of surgical repair with the use of a polypropylene prosthetic mesh. It is a rare type of hernia. Only four cases were found in literature. The sooner the disease is diagnosed and treated the better the prognoses will be since it will prevent hernia from strangulation and incarceration.

continuous positive airway pressure [CPAP] for ventilation for patients with multiple fracture ribs

The role of non-invasive positive pressure ventilation delivered through a face mask in patients with multiple fracture ribs is uncertain. We conducted a prospective, randomized study of continuous positive airway pressure [CPAP] given via a face mask for spontaneously breathing patients compared with intermittent positive pressure ventilation [IPPV] with endotracheal intubation [ETI] in 52 patients with multiple fracture ribs who required mechanical ventilation. The 52 mechanically ventilated patients were randomly divided into two treatment groups: the ET group [n=27] received mechanical ventilation with ETI, whereas patients in the CPAP group [n=25] received CPAP via a face mask with patient controlled analgesia [PCA]. Major complications, arterial blood gas levels, length of intensive care unit [ICU] stay and ICU survival rate were recorded Nosocomial infection was diagnosed in 10 to 21 patients in the ET group, but only in 4 of 22 in the CPAP group [P=0.001]. Mean PaO 2 was significantly higher in the ET group in the first 2 days [P < 0.05]. There were no significant differences in length of ICU stay between groups. Twenty CPAP patients survived, but only 14 of 21 intubated patients who received 1PPV [P < 0.01]. Non invasive CPAP with PCA led to lower mortality and a lower nosocomial infection rate, but similar oxygenation and length of ICU stay. This study supports the application of CPAP at least as a first line of treatment for multiple fractured ribs caused by blunt thoracic trauma

Hérnia intercostal abdominal / Abdominal intercostal hernia

Two cases of abdominal intercostal hernia are presented. One of them contained the colonic hepatic flexure and was caused by a thoraco-abdominal trauma ten months before the patient was referred to us. The second patient noticed the hernia few days after the trauma and the hernial sac content was a loop of small bowel. The clinical presentation of abdominal intercostal hernia is of an uncomplicated hernia, easily diagnosed on clinical examination. Further respiratory and digestive investigations are however essential to determine the content of the hernia sac. Treatment consisted of surgical repair. In one case we prefered the transperitoneal approach with the use of a Marlex mesh to repair the diaphragmatic defect. After one year of the operation the patient had no signs of recurrence. On the other patient we used the same approach and the defect was closed after the approximation of the 10§ and the 11§ ribs with pericostal suture. Nineth days after the operation the patient had no evidence of recurrence

Pronóstico de la fractura costal complicada / Prognosis of the complicated rib fracture

Con el propósito de estudiar el pronóstico de la fractura costal complicada estudiamos 114 pacientes, los que fueron divididos en dos grupos, Grupo A (n = 59) pacientes con lesiones circunscritas al tórax. Grupo B (n = 55) pacientes con lesiones torácicas asociadas a traumatismo encefalocraneano, fracturas de extremidades o traumatismo abdominal complicado. Grupo A. La edad fluctuó entre 12 y 80 años promedio 47,5 ñ 15,3. se asociaron a neumotórax 34%, a hemotórax 28,8%, a hemoneumotórax 37,2%, a contusión pulmonar 15,3%, a tórax volante 8,5% y a tórax volante y contusión pulmonar 6,8%, 11,9% fueron sometidos a toracotomía y 1,7% requirió ventilación mecánica. No hubo mortalidad. Grupo B. La edad fluctuó entre 6 y 68 años promedio 39,8 ñ 15,4. Se asociaron a neumotórax 16,4%, a hemotórax 34.5%, a hemoneumotórax 49,1%, a contusión pulmonar 32,7%, a tórax volante 9,1% y a tórax volante y contusión pulmonar 34,5%, y un porcentaje menor a otras lesiones extratorácicas; 21,8% fueron sometidos a toracotomía y 10,9% a cirugía extratorácica, 12,7% requirió ventilación mecánica. El 7,3% de estos pacientes falleció. El estudio comparativo entre los grupos muestra que el Grupo A es de significativa mayor edad p < 0,01, requirió menos ventilación mecánica p < 0,05 y presentó menor mortalidad (ningún caso) p < 0,05. Conclusión: la fractura costal con lesiones circunscritas al tórax (Grupo A) es de buen pronóstico