AAST 2013: Epidural Analgesia for Chest Trauma

This is my first in a series of reviews of abstracts for the coming AAST meeting in September. I’m going to pick some of the most interesting abstracts and discuss them here in advance of the meeting. I’ll be attending, so I can personally listen to the presentations to see if the work presented passes muster. I always encourage people to read the entire paper, or in this case listen to the whole presentation. Hopefully you’ve realized that the abstract does not always accurately portray what the research actually showed.

The first paper deals with the use of epidural analgesia for rib fractures. First off, this is a retrospective, cohort review of a large database (National Study of Cost and Outcomes of Trauma [NSCOT]). This means that there are shortcomings built in to the study from missing information and multiple submitters. Thankfully, many of these can be reduced using clever statistics.

The authors looked at records of patients with significant blunt trauma to the chest. They excluded all patients who had conditions that would have precluded epidural catheter placement (i.e. spine injury, coagulopathy). A total of 836 patients were identified as eligible for study, and 100 had epidurals placed. 

The following interesting findings were noted:

  • Epidural patients were older, had more rib fractures and were more likely to have a chest tube
  • Placement of an epidural catheter was much more likely if the patient was taken to a trauma center
  • Epidural placement was associated with a significant reduction in mortality at 30, 90 and 365 days. This is very interesting, especially since the study numbers are small.

Bottom line: Pain control for chest trauma using an epidural catheter is one of many items in our treatment toolbox. And although this abstract is more of a “this is how they do it” study, the mortality reduction is impressive. This occurred despite the epidural patients being older and with more rib fractures. In many centers, epidural catheters are used infrequently, and only in extreme cases. This study would seem to indicate that more aggressive usage, especially in the elderly (who are twice as likely to die from rib fractures), is warranted.

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Reference: The effect of epidural placement after blunt thoracic trauma. AAST 2013, Paper 27.

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