The effectiveness of an early management guideline for older patients following blunt thoracic injury.

Abstract

Thoracic injury is a leading cause of trauma related morbidity and mortality worldwide. Older patients (aged ≥65 years) who have sustained rib fractures following blunt chest wall trauma are at greater risk of serious pulmonary complications, prolonged hospital stay, and death when compared with the general population. The Blunt Chest-Wall Injury and Rib Fracture Pathway (BCWP) was introduced at our institution in July 2021 and advocates for early, aggressive analgesia, specialist support from the Acute Pain Service as well as consideration of regional techniques and Intensive Care Unit admission. A retrospective review of the prospectively maintained Alfred Hospital Trauma Registry identified all patients aged ≥ 65 years admitted to our Level 1 Adult Trauma Centre following blunt chest wall injury between the 1st of January 2019-1st of January 2024. The primary outcome measure was proportion of patients receiving an adequate analgesia (AA) regimen. Secondary outcomes included in-hospital mortality and hospital LOS. 2488 patients were admitted during the 5-year study period, with 1168 admitted prior and 1320 post BCWP introduction. Mean age was 78.3 (SD 8.4) and 78.8 (SD 8.3) while most patients [57.0 % (n = 666) & 56.3 % (n = 743)] were male. There was a significant difference in the proportion of patients who received AA, with 87.7 % (n = 1158) in the BCWP group and 76.4 % (n = 892) patients in the Pre-BCWP group (p < 0.001). Logistic regression analysis demonstrated a significant reduction in in-hospital mortality between patients receiving AA and those who had not (OR = 0.57, 95 % CI 0.36-0.91; p = 0.019). The results demonstrate that the introduction of the BCWP coincided with significantly improved rates early aggressive analgesia among older patients admitted with blunt chest wall injury. Given the vital role of early analgesia within the narrow window of opportunity to prevent significant complications this finding appears to support the introduction of the BCWP.