SGEM#324: Blow Away, Blow Away, Blow Away – Spirometry for Discharging Older Patients with Rib Fractures

Date: March 17th, 2021 Guest Skeptic: Dr. Emil Ejersbo Iversen is an emergency medicine resident at the University Hospital of Zealand, Denmark. He currently serves as Vice-Chair of the Danish Society for Emergency Medicine and Chair of the Young Doctors in Emergency Medicine in Denmark. He has a passion for FOAMed and is the creator of the Danish EM platform www.akutmedicineren.dk. Reference: Schuster et al. Spirometry not pain level predicts outcomes in geriatric patients with isolated rib fractures. J Trauma Acute Care Surg. 2020 Case: A 74-year-old woman who suffered a fall earlier today presents to the emergency department (ED) and is found to have five rib fractures to her right thorax, but no other injury. She is otherwise well, and her vitals are stable, but she is in some pain. Recent guidelines recommend admitting the patient to the intensive care unit (ICU), but the patient is eager to return home to her husband who is also well, and whom she claims will be able to help her. Background: Rib fractures are a common injury among the older population and can potentially lead to life-threatening complications such as pneumonia, pneumothorax or decreased inspiratory capacity. Some recent guidelines recommend admitting patients older than 65 years of age with two or more with rib fractures to an intensive care unit (ICU) or other step-down monitored setting [1]. Currently, patients with three or more rib fractures are often admitted for analgesia and monitoring and subsequently discharged without complications. Recent retrospective studies have suggested that early spirometry may be a useful indicator of prognosis in patients with multiple rib fractures [2]. Identifying patients with a good prognosis that could be safely discharged home with analgesia could potentially avoid unnecessary hospitalization. This would likely lower healthcare costs and decrease the risk of hospital-acquired infections. Spirometry includes metrics such as forced vital capacity (FVC), peak expiratory flow (PEF), forced expiratory volume 1 second (FEV1), and negative inspiratory force (NIF). The PEF has not been demonstrated to be closely correlated with patient outcomes [3]. However, FVC has been shown to correlate with patient outcomes and length of stay (LOS) in patients who have multiple rib fractures [4-5] These studies were limited by their retrospective observational nature. Hand grip strength has also been used to measure overall frailty. GeriEM guru Chris Carpenter has done some work in this area over ten years ago. His team found grip strength was weakly correlated with frailty in older ED patients [6]. Future research should confirm this association and assess the correlation of grip strength with other measures of frailty. Multiple other authors have investigated this simple and inexpensive tool for predicting frailty [7-8]. Clinical Question: Can spirometry testing identify patients 60 years and older with at least three rib fractures who can safely be discharged home from the ED? Reference: Schuster et al. Spirometry not pain level predicts outcomes in geriatric patients with isolated rib fractures. J Trauma Acute Care Surg. 2020 Population: Patients 60 years of age and older admitted to hospital with at least three rib fractures within 24 hours of injury Exclusions: Injury occurred >24hrs before presentation, significant additional musculoskeletal injury or cognitive impairment and able to cooperate with testing Exposure: Spirometry measuring (FVC, FEV1 and NIF) Comparison: Hand grip strength and pain assessment (VAS) Outcome: Primary Outcomes: Discharge disposition and length of stay (LOS) Secondary Outcomes:Mortality, pneumonia, intubation, unplanned transfer to higher level of care and readmission (within 30 days) Authors’ Conclusions: “Spirometry measurements early in the hospital stay predict ultimate discharge home,