Künt toraks travmasý sonucu izole kot fraktürü geliþen hastalarda analjezik tedavi ve solunum fizyoterapisinin komplikasyonlara etkisi

AMAÇ: Bu ileriye yönelik çalýþmanýn amacý künt toraks travmalarý nedeniyle izole kot fraktürü geliþen olgularda solunum fizyoterapisi ve aðrý kontrolünün, olasý komplikasyonlardan hemotoraks ve/veya pnömotoraks geliþim riski üzerine etkisinin araþtýrýlmasýdýr.
GEREÇ VE YÖNTEM: Bu ileriye yönelik çalýþmaya Çanakkale Onsekiz Mart Üniversitesi Týp Fakültesi Hastanesi Acil Servis ve Göðüs Cerrahisi Polikliniði’ne, künt toraks travmasý sonrasý ilk 24 saat içinde baþvuran ve izole kot fraktürü tespit edilen hastalar alýndý. Kot fraktürü olan hastalardan ilk baþvuru anýnda hemotoraks, pnömotoraks, yelken göðüs, atelektazi, pnömoni, akciðer kontüzyonu gibi ek yaralanmasý olmayan hastalar çalýþmaya dahil edildi. Hastalar, kapalý zarf usulü sadece analjezik tedavi verilecek hastalar (Grup A) ve analjezik tedavi ile birlikte solunum fizyoterapisi verilecek hastalar (Grup B) olarak iki ayrý gruba ayrýldý. Birinci ve ikinci kot fraktürü saptanan olgular ile üç veya daha fazla kot fraktürü saptanan ve ek organ yaralanmasý olmayan hastalar göðüs cerrahisi kliniðine, ek organ yaralanmasý olanlar ise ilgili kliniklere yatýrýlarak takibe alýndý. Bu kriterlerin dýþýnda kalan izole kot fraktürlü hastalar ise gerekli tedavileri düzenlenerek poliklinikten takip edildi. Olgular travmayý takip eden ilk hafta ve birinci ayýn sonunda fizik muayene ve radyolojik incelemeler ile deðerlendirildi.
BULGULAR: Çalýþmaya dahil edilen 114 hastanýn yaþlarý ortalama 56.3±16.4 (22–87) olarak bulundu. Hastalarýn 37’si (%32.5) kadýn, 77’si (%67.5) erkekti. A ve B gruplarýna 57’þer hastadan oluþtu. Hastalarýn en sýk geçirdikleri travma %31.6 ile ayný seviyeden düþme idi. Hastalarýn kot fraktürü sayýlarýnýn ortalamasý 2.6±0.7 (1–10), ortanca sayý 1.5 olarak bulundu. Bu 114 hastanýn 52’si (%45.6) hastanede yatarak tedavi edildi. Çalýþmaya alýnan hastalarýn yatýþ süreleri incelendiðinde hastalarýn ortalama yatýþ süresi 4.0±1.1 idi. Tedavi ve takipleri sonucunda çalýþmaya alýnan 114 hastanýn 28’inde (%24.6) kot fraktürü geliþen tarafta plevral efüzyon saptandý. Hastalarda plevral efüzyon geliþme durumunun gruplara göre daðýlýmý incelendiðinde B grubundaki hastalarda (%43.9) A grubundaki hastalardan (%5.3) istatistiksel olarak anlamlý þekilde daha fazla plevral efüzyon geliþimi izlendi (p<0.0001). Çalýþmamýzda takipler sonucunda A grubundaki hiçbir hastaya müdahale gerekmezken, B grubundaki dört hastaya hemotoraks tanýsýyla tüp torakostomi uygulandý (p<0.05).
TARTIÞMA: Çalýþmamýzda künt toraks travmasý sonucu izole üç ve daha fazla kot fraktürü geliþen hastalarda solunum fizyoterapisi uygulamalarýnýn gecikmiþ hemotoraks geliþme riskini önemli derecede artýrdýðý, minimal hemotorakslarýn (<300 ml) uygun takip prosedürlerine uyulduðu takdirde spontan regrese olabileceði ve ek cerrahi müdahaleye gerek olmayabileceði tespit edilmiþtir. Künt toraks travmasý sonucu üç ve daha fazla kot fraktürü olan hastalara eðer solunum fizyoterapisi uygulanmasý planlanýyorsa hastalarýn hastaneye yatýrýlarak takip ve tedavi edilmesi olasý riskleri içeren ek komplikasyonlar geliþebilmesi açýsýndan önerilebilir.

The effects of analgesic treatment and chest physiotherapy on the complications of the patients with rib fractures that arise from blunt chest trauma

BACKGROUND: This prospective study aims to investigate the effect of chest physiotherapy and analgesic therapy on the possible complications of isolated rib fractures attributable to blunt thoracic trauma, such as hemothorax and pneumothorax.
METHODS: Patients who presented to Çanakkale Onsekiz Mart University School of Medicine Hospital’s Emergency Department and Thoracic Surgery outpatient clinics within the first 24 hours of the post-traumatic period and did not have additional intrathoracic complications at presentation with blunt thoracic trauma and who were diagnosed with isolated rib fractures were enrolled in this prospective research study. The groups were designated as the patients who would receive analgesic treatment only (Group A) and the patients who would receive chest physiotherapy and analgesic treatment together (Group B). Patients who had first and second rib fractures or three or more rib fractures and who did not have additional organ injury were hospitalized in the Thoracic Surgery clinics; patients who had other organ trauma were hospitalized in related clinics. Patients were reassessed on their seventh and 30th post-traumatic days with physical examination and radiologic studies.
RESULTS: The mean age of the 114 patients were 56.3±16.4 (22–87). There were 37 (32.5%) women and 77 (67.5%) men. Each group included 57 patients. The most common form of trauma was the same-level falls (31.6%). The mean number of rib fractures of all participants was 2.6±0.7 (1–10); the median number was 1.5. Fifty-two (45.6%) patients were hospitalized. The mean length of stay was 4.0±1.1 days. At the end of their treatment and follow-up periods, pleural effusion was found in 28 patients (24.6%) out of 114 enrolled at the side of trauma. Group B had a higher number of patients with pleural effusion (43.9%) than group A (5.3%). We performed tube thoracostomy in four patients, all of which were in group B (p<0.05).
CONCLUSION: As a result of this study, chest physiotherapy maneuvers have increased the incidence of late hemothorax in patients with three or more isolated rib fractures. Also, minimal hemothoraces (<300 ml) may spontaneously regress, and no additional surgical treatment are required if the proper follow-up procedures are performed. It is advisable to hospitalize the blunt thoracic trauma patients who have three or more rib fractures and who are planned to undergo chest physiotherapy and or are prone to develop additional complications because of possible risks.