***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The incidence of tracheostomy , length of intensive care unit ( ICU ) and total hospital stay , and duration of ventilatory support were evaluated prospect ively in 28 patients who had multiple rib fractures . The patients were r and omly divided into two groups : 13 patients were given st and ard morphine parenteral analgesia and constituted the control group ( Group 1 ) , and 15 patients had thoracic epidural catheter placement within 72 hours from the time of admission to the ICU ( Group 2 ) . Group 2 patients had less ventilator-dependent time compared with control patients ( 3.07±1.35 days vs. 18.23±8.12 days , p < 0.05 ) , less time in ICU ( 5.93±1.44 days vs. 18.69±5.25 days , p < 0.02 ) , and a shorter hospital stay ( 14.85±2.21 days vs. 47.69±14.67 days , p < 0.03 ) . Group 2 patients also had a lower incidence of tracheostomy versus control patients ( 6.7±6.7 % vs. 38.5±14.0 % , p < 0.05 ) . The authors believe that continuous thoracic epidural morphine analgesia may provide distinct pulmonary and economic advantages in patients with multiple rib fractures BACKGROUND Providing analgesia for patients with rib fractures continues to be a management challenge . The objective of this study was to examine our experience with the use of a continuous intercostal nerve block ( CINB ) . Although this technique is being used , little data have been published documenting its use and efficacy . We hypothesized that a CINB would provide excellent analgesia , improve pulmonary function , and decrease length of stay ( LOS ) . METHODS Consecutive adult blunt trauma patients with three or more unilateral rib fractures were prospect ively studied over 24 months . The catheters were placed at the bedside in the extrathoracic , paravertebral location , and 0.2 % ropivacaine was infused . Respiratory rate , preplacement ( PRE ) numeric pain scale ( NPS ) scores , and sustained maximal inspiration ( SMI ) lung volumes were determined at rest and after coughing . Parameters were repeated 60 minutes after catheter placement ( POST ) . Hospital LOS comparison was made with historical controls using epidural analgesia . RESULTS Over the study period , 102 patients met inclusion criteria . Mean age was 69 ( 21 - 96 ) years , mean injury severity score was 14 ( 9 - 16 ) , and the mean number of rib fractures was 5.8 ( 3 - 10 ) .  Mean NPS improved significantly ( PRE NPS at rest = 7.5 vs. POST NPS at rest = 2.6 , p < 0.05 , PRE NPS after cough = 9.4 , POST after cough = 3.6 , p < 0.05 ) which was associated with an increase in the SMI ( PRE SMI = 0.4 L and POST SMI = 1.3 L , p < 0.05 ) . Respiratory rate decreased significantly ( p < 0.05 ) and only 2 of 102 required mechanical ventilation . Average LOS for the study population was 2.9 days compared with 5.9 days in the historical control . No procedural or drug-related complications occurred . CONCLUSION Utilization of CINB significantly improved pulmonary function , pain control , and shortens LOS in patients with rib fractures BACKGROUND This prospect i ve study was undertaken to evaluate the efficiency of intercostal nerve block ( ICNB ) with 0.5 % bupivacaine ( Marcaine ) for pain relief in patients with rib fractures and to correlate the degree of pain relief with changes in the peak expiratory flow rate ( PEFR ) and oxygen saturation ( Sao2 ) . METHODS Twenty-one consecutive adult patients admitted with rib fractures associated with severe pain formed the basis of the study . Chest pain was scored on a four-point scale before ICNB , 1 hour after ICNB , and 24 hours after ICNB . Sao2 was measured before and immediately after ICNB . PEFR was measured before and immediately after ICNB . RESULTS Pain score and PEFR before and after ICNB showed statistically significant differences ( p = 0.0000 , df = 20 ) . There was a significant difference between Sao2 before and after ICNB . CONCLUSION Significant increases in Sao2 and PEFR occur after ICNB with 0.5 % bupivacaine , which also provides sustained analgesia , leading to improvement in respiratory mechanics BACKGROUND In studies of trauma patients with rib fractures , conclusions on the benefits derived from epidural analgesia are inconsistent . The purpose of this study was to further evaluate placement and efficacy of epidural analgesia nationwide . METHODS This was a retrospective cohort study of prospect ively gathered data from the National Study on Cost and Outcomes of Trauma data base , a multisite prospect i ve study of injured patients aged 18 years to 84 years . Patients were treated at 69 participating hospitals ( 18 Level I trauma centers and 51 nontrauma centers ) across the United States . Our analysis was limited to patients with a blunt mechanism of injury and a thoracic maximum Abbreviated Injury Scale ( MAXAIS ) score of 2 or greater . Excluded were patients who were not potential c and i date s for epidural placement , such as patients with significant head and spine injuries ( head MAXAIS score > 2 or spine MAXAIS score > 2 ) , significant neurologic impairment ( best motor Glasgow Coma Scale [ GCS ] score < 4 ) , unstable pelvic fractures , coagulopathy , or those who died within 48 hours . RESULTS The National Study on Cost and Outcomes of Trauma data base contains 5,043 patients , of whom 836 ( 16.5 % ) were identified as potential c and i date s for epidural placement . Of patients included in the study , 100 patients ( 12 % ) had epidural catheters placed . The likelihood of epidural catheter placement  was significantly higher in trauma centers as compared with nontrauma centers ( adjusted odds ratio , 3.06 ; 95 % confidence interval [ CI ] 1.80–5.22 ) . In the epidural group compared with those not receiving a catheter , the adjusted ( including trauma center status ) odds of death in patients with three or more rib fractures at 30 , 90 , and 365 days was 0.08 ( 95 % CI , 0.01–0.43 ) , 0.09 ( 95 % CI , 0.02–0.42 ) , and 0.12 ( 95 % CI , 0.04–0.42 ) , respectively . CONCLUSION Trauma centers are more likely to place epidural catheter in patients with rib fractures . In this multicenter study , epidural catheter placement was associated with a significantly decreased risk of dying in patients with blunt thoracic injury of three or more rib fractures . LEVEL OF EVIDENCE Therapeutic study , level II Interpleural block ( IPB ) was compared with epidural block ( EB ) in 17 adults with unilateral multiple rib fractures and hemopneumothorax . The study was a r and omized , crossover , before-after trial on the first and second hospital days . An IPB catheter was inserted along with a chest tube , and an upper thoracic EB was also established in the same patient . We administered 10 ml of 1 % lidocaine for both blocks . The range of thermohypesthesia was unilateral and shorter in IPB , whereas it was bilateral and wider in EB . The effects of pain relief were almost the same . Respiratory rate decreased , and PaO2 tended to elevate similarly . In IPB , systemic blood pressure changed minimally , but it fell significantly in EB , which would be a disadvantage of EB in trauma patients . Serum levels of lidocaine  were similar and in the safe range . The technique of IPB seemed to be easier than EB . In conclusion , IPB with lidocaine is as effective for pain relief as EB OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity OBJECTIVE The purpose of this study was to determine the magnitude and duration of pain and disability in patients with rib fractures treated using current st and ard therapy .  This was a prospect i ve case series . METHODS Injured patients with a chest radiographic diagnosis of one or more rib fractures between June 1 , 2001 , and October 31 , 2001 , were asked to participate .  Pain levels were assessed at days 1 , 5 , 30 , and 120 after injury using a visual pain scale ( 0 - 10 ) . Disability at 30 days was assessed using the SF-36 Health Status Survey , and the total number of days lost from work/usual activity was recorded at day 120 . The setting was a university-based Level I trauma center . RESULTS Forty patients with a mean of 2.7 + /- 1.6 rib fractures were enrolled . Twenty-three patients had isolated rib fractures and 17 patients had associated extrathoracic injuries .  Mean rib fracture pain was 3.5 + /- 2.1 at 30 days and 1.0 + /- 1.4 at 120 days . For patients with associated extrathoracic injuries , rib pain was equivalent to pain in the rest of the body at all intervals . When compared with the chronically ill reference population of the R AND Medical Outcomes Study , our patients as a group were more disabled at 30 days ( p < 0.001 ) in all categories except emotional stability , where they showed equivalent disability , and in their perception of general health , where they were significantly less disabled ( p < 0.001 ) . The total mean days lost from work/usual activity was 70 + /- 41 . Patients with isolated rib fractures went back to work/usual activity at a mean of 51 + /- 39 days compared with 91 + /- 33 days in patients with associated extrathoracic injuries ( p < 0.01 ) . CONCLUSION Rib fractures are a significant cause of pain and disability in patients with isolated thoracic injury and in patients with associated extrathoracic injuries . Developing new therapies to accelerate pain relief and healing would substantially improve the outcome of patients with rib fractures Severe blunt chest trauma can produce multiple rib fractures , flail segments , and pulmonary contusions . All of these injuries produce pain and diminished pulmonary function . The effectiveness of intrapleural and epidural administration of bupivacaine was prospect ively evaluated in 19 patients with severe chest trauma .  Pain relief and pulmonary function were evaluated for 72 hours after catheter placement . Epidural administration of bupivacaine significantly reduced pain at rest and with motion compared with the intrapleural route ( p < 0.05 ) . Parenteral narcotic use was also significantly less in the epidural group ( p < 0.05 ) . Negative inspiratory pressure and tidal volume were significantly increased with epidural anesthesia ( p < 0.05 ) . Vital capacity , FIO2 , minute ventilation , and respiratory rate were not affected . Mild hypotension was a common complication with epidural catheters . We conclude that continuous epidural analgesia is superior to intrapleural block and significantly improves tidal volume and negative inspiratory pressure BACKGROUND The effectiveness of the nonsteroidal anti-inflammatory drug ketorolac in reducing pulmonary morbidity after rib fractures 
    Output:
    
The majority of included studies examined epidural analgesia .
Epidural analgesia was associated with lower short-term pain scores in most studies , but the quality and quantity of evidence were very low , and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions .
We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma , but the overall quality of evidence supporting these modalities is low in trauma patients .
These recommendations are based on very low- quality evidence but place a high value on patient preferences for analgesia .