A 65 yo patient with COPD falls and break two ribs. The patient appears well and is in no distress. Pain is controlled and the patient is asking to go home. Osteopenia, likely from previous steroid use, caused a simple fall to fracture two ribs. There is no lung injury. Why not send the patient home with instructions to return for any worsening, and a prescription for pain meds?
Scoring System
A rib fracture scoring system was developed by Battle et al 2 in 2014 and lists the following criteria.
Based on this scoring system, our patient has:
- 6 points for age (1 point for every 10 years)
- 6 points for 2 rib fractures (3 points for each rib)
- 5 points for COPD
Total= 17 with a 52% chance of complications !!
(mortality, pulmonary complications, ICU admission, and LOS in hospital of > 7 days- see comments below)
Further Evidence
In addition, there is good evidence 3,4,5,6,7 that patients 65 years or older with 2 or more rib fractures require ICU admission even when well appearing. Elderly patients have almost 2x the risk of mortality compared with the young, independent of comorbidities 7. Also, the elderly have 5x the risk of mortality from pneumonia after rib fractures 7. So our patient not only should not be discharged, they should be admitted to the ICU. A frank discussion with this patient about their 52% mortality risk and need for ICU admission is needed before they decide to leave the ER.
For more about these scoring systems, evaluation of patients with rib fractures, medical and surgical treatment, see the Nov 2021 issue of Emergency Medicine Practice, Emergency Dept. Management of Rib Fractures.
References
- Maher P. Emergency Department management of rib fractures. Emerg Med Pract. 2021 Nov;23(11):1-24. Epub 2021 Nov 1. PMID: 34669317. EBMedicine
- Battle C, Hutchings H, Lovett S, et al. Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model. Crit Care.2014;18(3):R98. (Prospective cohort; 276 patients) PubMed
- Tignanelli CJ, Rix A, Napolitano LM, et al. Association between adherence to evidence-based practices for treatment of patients with traumatic rib fractures and mortality rates among US trauma centers. JAMA Netw Open. 2020;3(3):e201316. (Retrospective cohort; 625,617 patients) PubMed
- Brasel KJ, Moore EE, Albrecht RA, et al. Western Trauma Association Critical Decisions in Trauma: management of rib fractures. J Trauma Acute Care Surg.2017;82(1):200-203. (Practice guideline) PubMed
- Pieracci FM, Majercik S, Ali-Osman F, et al. Consensus statement: surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury.2017;48(2):307-321. (Practice guideline) PubMed
- Bowman JA, Nuño M, Jurkovich GJ, et al. Association of hospital-level intensive care unit use and outcomes in older patients with isolated rib fractures. JAMA Netw Open. 2020;3(11):e2026500. (Retrospective cohort; 23,951 patients) PubMed
- Battle CE, Hutchings H, Evans PA. Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis. Injury. 2012;43(1):8-17. (Review) PubMed
Last Updated on January 25, 2023
Thank you for this. I’m really happy / humbled to see our work being used this way. Just one thing, I would just like to stress that the 52% risk refers to complications, rather than mortality alone. We used a composite outcome, that included mortality, onset of pulmonary complications, need for ICU admission and 7 days or more hospital LOS.
Thank you for the clarification Ceri !