this pathway is intended as a guide only and does not

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Facility: Liverpool Hospital

CLINICAL PATHWAY -

FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE

NO WRITING of 10

FAMILY NAME MRN

GIVEN NAMES MALE FEMALE

D.O.B. ______/_______/_________ M.O.

ADDRESS

LOCATION / WARD

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THIS PATHWAY IS INTENDED AS A GUIDE ONLY AND DOES NOT REPLACE CLINICAL JUDGEMENT

STAFF MEMBERS DIRECTLY INVOLVED IN THE PATIENT’S CARE ARE RESPONSIBLE FOR COMPLETING THIS FORM

Instructions for use:

Patients recognised as fitting the criteria should start the clinical

pathway immediately

Start a new page for each day

A patient taken off a clinical pathway must have reasons clearly

documented

On completion, this form should remain with the clinical record

All staff involved with patient care or management are encouraged to

complete the pathway

PATIENTS MUST MEET ALL BELOW CRITERIA FOR USE

1. Age > 14 years

2. Patients with fractured ribs or a fractured sternum diagnosed

radiologically or clinically should be commenced on this path-

way

BLUNT CHEST TRAUMA FRACTURED RIBS

FRACTURED STERNUM

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Blunt Chest Injury / Fractured Ribs (Clinically or Radiologically)

All Patients

Regular paracetamol charted

PCA commenced with IV Fluids

If NO PCA then must have regular analgesia charted - first dose must be given prior to leaving Emergency Department (+/- breakthrough doses charted)

NO

Request admission to Trauma Ward

YES

Requires ICU admission, must have ICU review prior to leaving ED

Pain team consideration for regional block techniques

Consider early Geriatrician

involvement for 65

High risk of delirium/previous delirium in hospital

Frailty score 5 - 8 (page 8)

ON CALL PAGE # 50323

Is Any of the Following Present? Flail segment

4 Ribs

2 significantly displaced fractured ribs

Chest wall deformity or defect

Significantly displaced fractured sternum

Hypoxia (supplemental oxygen required to maintain SpO2 >94%)

Lung contusions (on CXR or CT)

Chronic respiratory failure or cardiac failure

Age 65

Consider Early Rib fixation

(Refer to Potential Criteria on page 7 in document)

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EMERGENCY DEPARTMENT CHECKLIST

Must be completed prior to ED discharge

ICU Review as per diagram

INVESTIGATIONS / PLAN

Documented plan by admitting team

CXR / Bloods / ECG

VTE prophylaxis (if appropriate)

Stool softeners charted

Regular medications charted

If NSAIDS commenced also chart PPI / regular paracetamol

ANALGESIA

PCA charted and commenced (ideally fentanyl), IV Fluids charted commenced

APS registrar contacted for all patients starting PCA for consideration of regional

block

If not appropriate for PCA must have regular analgesia charted (+/- breakthrough

doses)

OTHER

Powerchart physiotherapy referral

Page ED Physiotherapist (#50816) for review

If unable to complete any of the above, please document why: _______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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Date Day of Admission

Surgical team assessment and definitive plan documented in notes

Surgical team to consider early rib fixation - see criteria

Fractured sternum patients to have ECG, troponin and Echo

Tertiary Survey completed

Careful consideration of geriatric patients on multimodal analgesia

Regular medications charted (stool softeners / chemical VTE / NSAIDS / PPI)

Tests / Investigations ordered reviewed (CXR / Pathology / CT)

Patients meeting frailty score 5 - 8 (page 8) should be referred to geriatrics

Medical Assessment: To be completed daily by admitting medical team

Nursing Assessment: completed daily

Ask patient to take a deep breath and cough, ask patient to rate pain 0 = no pain to 10 = worst pain, document score. Aim for pain score < 3

Check pain score 2/24. If pain score 5 contact admitting team

Regular medications administered (stool softeners / chemical VTE / NSAIDS / PPI)

Ensure prn medication charted, patient may need additional dose if pain 5 and unable to cough effectively

Patient sitting up in chair unless contraindicated. (If unable elevated head of bed as tolerated)

Encourage hourly breathing exercises

Mobilise at least three times a day unless contraindicated (don’t wait for physiotherapy)

Physiotherapy referral via powerchart as well as page physiotherapy

Consider other allied health interventions

Acute Pain Service (APS): completed daily

Review both IV and oral medication

Review patient and consider if suitable for regional block and discuss with admitting team. If not suitable for block please document why not

Physiotherapy: completed daily

Physiotherapy assessment completed and plan documented

Patient is provided with a copy of the Active Breathing Technique (ACBT) located at back of pathway

Mobilise patient if appropriate

Additional Comments: if unable to complete

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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CLINICAL PATHWAY -


Date Day One


Surgical team to consider early rib fixation - see criteria

Fractured sternum patients to have ECG, troponin and Echo

Tertiary Survey completed













Physiotherapy referral via powerchart, page physio (also consider other allied health interventions)



Consider regional block (based on individual patient assessment). If not suitable for block please document why not




Mobilise patient in ward / chair as appropriate

Additional Comments:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

FAMILY NAME MRN


D.O.B. ______/_______/_________ M.O.

ADDRESS

LOCATION / WARD

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Date Day Two


Tertiary Survey completed (if appropriate)













Physiotherapy referral via powerchart (also consider other allied health interventions)



Consider regional block (based on individual patient assessment.). If not suitable for block please document why not




Mobilise patient in ward / chair as appropriate

Additional Comments: if unable to complete

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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CLINICAL PATHWAY -


Flail Chest

Non-intubated patients with flail chest and worsening respiratory function

Intubated patients with flail chest

Patients with extensive and/or bilateral flail chest without respiratory failure

Flail sternum

Chest Wall Deformity/ Defect

Loss of thoracic volume or significant deformity that may limit chest wall function

Open chest defect

Rib perforation of vital structures and/or pulmonary herniation

Fractured Ribs - non-flail

Patients with multiple displaced fractured ribs

Painful non-union

Pain Control

Uncontrolled pain despite multimodal analgesia including regional blocks and IV narcotics

Indications

Contra-indications

Patient unlikely to survive due to other injuries or age or multiple co-morbidities

Other injuries that will likely prolong tracheal intubation and mechanical ventilation e.g. significant head injury, spinal cord injury resulting in paralysis of some or all of the respiratory muscles etc.

Any contra-indication to surgery including severe immunosuppression or severe chronic disease

Pregnant women

How to refer patients

The Trauma Department is the point of contact for referrals for possible rib fixation - trauma will review and involve Cardiothoracic as appropriate

3D reconstructions of the chest wall need to be organised (request from CT Radiographer)

Referrals and consults should be made within 24-48 hours of admission - Contact the Trauma Fellow or Trauma Consultant directly

FAMILY NAME MRN


D.O.B. ______/_______/_________ M.O.

ADDRESS

LOCATION / WARD

CRITERIA FOR RIB FRACTURE FIXATION

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CLINICAL PATHWAY -


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ACBT - Active Cycle of Breathing Technique

Repeat _____ cycles

Every 1 - 2 hours

Left side lying Right side lying Sitting upright

Start Here!

____ Deep Breaths

3 Seconds Hold

____ Relaxed Breaths ____ Relaxed Breaths

____ Coughs

____ Relaxed Breaths

Created by Physiotherapy Department, Liverpool Hospital Updated November 2017

____ Coughs

____ Deep Breath 3 Seconds Hold

____ Huffs

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NO WRITING of 10

INTENTIONALLY LEFT BLANK

this pathway is intended as a guide only and does not

Documents