Phase 3: RESULTS

Group 4: Thoracic Injuries

• Clinical algorithm for the management of intubated and non-intubated patients following thoracic injuries
  
  
• Best Practice Recommendation Consensus
  • Recommendation 1
  • Recommendation 2

RECOMMENDATION 1:

An aggressive physiotherapy program including DBE and mobilization should be instituted in non intubated patients following thoracic trauma ASAP after insertion of ICD, while ensuring sufficient pain management. This program should focus on patient empowerement and include patient education with regards to upright positioning; cough with wound support and early activity. WEAK RECOMMENDATION The implementation of this program ASAP after ICD insertion decreased the LOS in two studies (Senekal et al 1995; Ngubani et al 1999) and decreased the number of physiotherapy interventions needed in one study (Ngubani et al 1999). Implementing this strategy in non intubated patients thus has potential economic advantages without increasing the burden. However the potential harm is not clear. The recommendation is based on LOW QUALITY EVIDENCE: Two RCT’s (Senekal et al 1995; Ngubani et al 1999 and one observational study (Varela et al 2006). The quality of the evidence from the RCT’s were downgraded due to high risk of bias (refer to table 2); and imprecision of sample and data. There was insufficient cause to upgrade the observational study due to indirectness (thoracic surgery population) and the limited effect size (RR 0.56).

RECOMMENDATION 2:

The early initiation of periodic CPAP in patients that are awake; hemodynamically stable and have sustained injuries to the chest wall should be considered before intubation. WEAK RECOMMENDATION The implementation of CPAP decreased mortality and nosocomial infection rate but did not affect LOS (Gunduz et al 2005). In an earlier study (Bollinger et al 1990) the implementation of CPAP did affect mean difference in ICU LOS (-2.8 days CI -4.27: -1.33) and hospital stay (-6.2 days CI -9.98:-2.42) The cost could potentially be affected because of high cost of intubation but has not been measured. Potential harm is not clear. Based on LOW QUALITY EVIDENCE Two RCT’s (Gunduz et al 2005; Bollinger et al 1990) was downgraded due to inconsistent results; high risk of bias and imprecision of sample size and data.