A Comparison of Scoring Systems to Identify Patients at Increased Risk From Traumatic Rib Fractures

Patients with rib fractures from traumatic injuries may suffer increased morbidity, an increased hospital stay, an increased length of time in the intensive care unit (ICU), pulmonary complications resulting in the need for mechanical ventilation, and increased mortality. Some studies have focused on developing specific scoring systems to triage and to help identify patients most at risk for the most severe complications. One such protocol is the RibScore. At our institution, we use and modified the Pain, Inspiratory Effort, Cough score (mPIC score) to help stratify patients most likely to require ICU admission. This study compared our protocol with the previously published and validated RibScore.

This was a retrospective review of patients with traumatic rib fractures presenting to our trauma center between 2018 and 2022. The primary outcomes evaluated were overall length of stay (LOS) and ICU LOS, with a secondary outcome of rates of intubation. We collected basic patient demographics, as well as data on methods to control analgesia, whether a nerve block was performed, and if the patient was mobilized. We calculated an mPIC score and a RibScore for these patients. We used an initial mPIC score of <5 to indicate the need for ICU admission. Statistical analysis was performed with a value of a P value of <0.05 deemed statistically significant.

Through Cox regression analysis we found that an mPIC score <5 is associated with a doubling of both the risk to remain in ICU, and in hospital, compared to an mPIC score of ≥5. The overall LOS was also significantly higher in the former (median 4 d versus 6 d, P = 0.037). It was also associated with higher rates of intubation (14% versus 2.3%, P = 0.021) and ICU admission (82% versus 51%, P = 0.007). Similarly, a RibScore of 4-6 was associated with a statistically significant increase in the median overall LOS (2 d; P = 0.008) and ICU LOS (2 d; P < 0.001), as well as a statistically significant increase in the rates of intubation (14% versus 2.1%, P < 0.006) and ICU admission (83% versus 51%), when compared to a RibScore of 0-3.

Patients with rib fractures are at an increased risk of morbidity and mortality. The use of radiographic signs has been used to aid clinicians in accurately stratifying patients with traumatic rib fractures who are at increased risk. Here, we utilize two methods of stratifying patients, the previously described RibScore, which we used as our gold standard and our institutional mPIC score. As has been previously published, we found that a RibScore>3 is associated with significant increases in the rates of intubation. We also found an increase in overall and ICU LOS; this correlates with our mPIC score of <5. Comparing the two scores, we found a percentage agreement of 88.7%. One advantage of our mPIC score over the RibScore is its ability to be easily and rapidly scored at the bedside upon initial patient presentation and throughout the patient's stay by both physicians and nurses, triaging patients upon admission and at later times, during their stay. To our knowledge this is the first time another method of stratifying patients has been compared to the RibScore, and using the mPIC score may give the clinician an opportunity to identify patients most at risk, aiding in their disposition and management.