Andrew R. Doben

Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation

PURPOSE The goal of this study was to determine the impact of surgical rib fixation (SRF) in a treatment protocol for severe blunt chest trauma. MATERIALS AND METHODS Patients with flail chest admitted between September 2009 and June 2010 to our level I trauma center who failed traditional management and underwent SRF were matched with an historical group. Outcome variables evaluated include age, injury severity score, intensive care unit length of stay (LOS), hospital LOS, ventilator days, total number of rib fractures, and total number of segmental rib fractures. RESULTS The 2 groups were similar in age, injury severity score, intensive care unit LOS, hospital LOS, total number of rib fractures, and total segmental rib fractures. The operative group demonstrated a significant reduction in total ventilator days as compared with the nonsurgical group (4.5 [0-30] vs 16.0 [4-40]; P = .040). Patients with SRF were permanently liberated from the ventilator within a median of 1.5 days (0-8 days). CONCLUSIONS Surgical rib fixation resulted in a significant decrease in ventilator days and may represent a novel approach to decreasing morbidity in flail chest patients when used as a rescue therapy in patients with declining pulmonary status. Larger studies are required to further identify these benefits.

Safety and efficacy of heparin or enoxaparin prophylaxis in blunt trauma patients with a head abbreviated injury severity score >2

BACKGROUND Timing and type of chemoprophylaxis (CP) that should be used in patients with traumatic brain injury (TBI) remains unclear. We reviewed our institutions experience with low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) in TBI. METHODS The charts of all TBI patients with a head abbreviated injury severity score >2 (HAIS) and an intensive care unit length of stay >48 hours admitted during a 42-month period between 2006 and 2009 were reviewed. CP was initiated after intracranial hemorrhage was considered stable. We reviewed all operative notes and radiologic reports in these patients to analyze the rate of significant intracranial hemorrhagic complications, deep venous thrombosis, or pulmonary embolus. RESULTS A total of 386 patients with TBI were identified; 158 were treated with LMWH and 171 were treated with UFH. HAIS was significantly different between the LMWH (3.8 ± 0.7) and UFH (4.1 ± 0.7) groups; the time to initiation of CP was not. The UFH group had a significantly higher rate of deep venous thrombosis and pulmonary embolus. Progression of ICH that occurred after the initiation of CP was significantly higher in the UFH-treated patients (59%) when compared with those treated with LMWH (40%). Two patients in the UFH group required craniotomy after the initiation of CP. CONCLUSION LMWH is an effective method of CP in patients with TBI, providing a lower rate of venous thromboembolic and hemorrhagic complications when compared with UFH. A large, prospective, randomized study would better evaluate the safety and efficacy of LMWH in patients suffering blunt traumatic brain injury.

Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines

Please cite this article as: Pieracci Fredric M, Majercik Sarah, Ali-Osman Francis, Ang Darwin, Doben Andrew, Edwards John G, French Bruce, Gasparri Mario, Marasco Silvana, Minshall Christian, Sarani Babak, Tisol William, VanBoerum Don H, White Thomas W.Consensus Statement: Surgical Stabilization of Rib Fractures Rib Fracture Colloquium Clinical Practice Guidelines.Injury http://dx.doi.org/10.1016/j.injury.2016.11.026

Current Concepts in Cutaneous Melanoma: Malignant Melanoma

Melanoma of the skin is one of the most clinically important skin and soft tissue lesions encountered by the practicing general surgeon. If it is properly diagnosed and treated in its early stages, its prognosis and outcome are uniformly favorable. The current concepts in malignant melanoma are discussed.

Cervical Spine Injuries and Helmet Laws: A Population-Based Study

BACKGROUND: To assess the incidence of cervical spine (C-spine) injuries in patients admitted after motorcycle crash in states with mandatory helmet laws (MHL) compared with states without helmet laws or selective helmet laws. METHODS: The Nationwide Inpatient Sample from the Healthcare and Utilization Project for the year 2008 was analyzed. International Classification of Diseases and Health Related Problems, Ninth Edition codes were used to identify patients with a diagnosis of motorcycle crash and C-spine injuries. National estimates were generated based on weighted analysis of the data. Outcome variables investigated were as follows: length of stay (LOS), in-hospital mortality, hospital teaching status, and discharge disposition. States were then stratified into states with MHL or selective helmet laws. RESULTS: A total of 30,117 discharges were identified. Of these, 2,041 (6.7%) patients had a C-spine injury. Patients in MHL states had a lower incidence of C-spine injuries (5.6 vs. 6.4%; p = 0.003) and less in-hospital mortality (1.8 vs. 2.6%; p = 0.0001). Patients older than 55 years were less likely to be discharged home (57.5% vs. 72.5%; p = 0.0001), more likely to die in-hospital (3.0% vs. 2.1%; p = 0.0001), and more likely to have a hospital LOS more than 21 days (7.7% vs. 6.2%; p = 0.0001). CONCLUSION: Patients admitted to the hospital in states with MHLs have decreased rate of C-spine injuries than those patients admitted in states with more flexible helmet laws. Patients older than 55 years are more likely to die in the hospital, have a prolonged LOS, and require services after discharge. LEVEL OF EVIDENCE: III.

Quantifying and exploring the recent national increase in surgical stabilization of rib fractures

BACKGROUND Surgical stabilization of rib fractures (SSRF) has become pivotal in the management of severe chest injuries. Recent literature supports improved outcomes and mortality in severe fracture and flail chest patients who undergo SSRF compared with nonoperative management (NOM). A 2014 National Trauma Data Bank review provided a point prevalence of 0.7% SSRF in flail patients. We hypothesize that this prevalence is increasing and that temporal, regional, and American College of Surgeons (ACS) trauma designation vary in SSRF utilization. METHODS Retrospective National Trauma Data Bank data were extracted for years 2007 to 2014 for patients with rib fractures. Cases were divided into SSRF versus NOM. SSRF frequencies were analyzed across year, region, and ACS level. Patient demographics, injury severity score, number of fractured ribs, and hospital characteristics were identified for multivariable analysis. RESULTS Between 2007 and 2014, 687,137 rib fracture patients were identified; 29,981 (4.36%) underwent SSRF. SSRF increased by 76% nationally during the review period (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.50–1.67; p < 0.001). Compared with the north, SSRF was used more in the west (OR, 1.6; 95% CI, 1.57–1.71), south (OR, 1.48; 95% CI, 1.43–1.54), then midwest (OR, 1.4; 95% CI, 1.34–1.46; p < 0.001). Although likelihood of SSRF is higher at ACS Level I (LI) centers compared with Level II (LII) centers (OR, 0.67; 95% CI, 0.65–0.69) or Level III (LIII) (OR, 0.24; 95% CI, 0.22–0.26); p < 0.001), frequency of SSRF increased dramatically at lower-level centers from 2007 to 2014 (LI, 41.4%; LII, 53.6%; LIII, 60.0%). Overall SSRF mortality was 1.58% (NOM, 5.3%; p < 0.001), decreasing significantly between 2007 and 2014 (p < 0.0001). ACS LII had higher mortality than LI (OR, 1.82; 95% CI, 1.39–2.39; p < 0.0001), controlled by Injury Severity Score. CONCLUSION Utilization of SSRF has risen considerably nationwide. Prevalence varies by region and ACS level. Although greatest growth is occurring at LII hospitals, mortality is also the highest at these centers. Further research is needed to determine the need for regionalization of care and center of excellence designation. LEVEL OF EVIDENCE Epidemiological study, level III.

Reply to “open reduction and internal fixation of rib fractures in polytrauma patients with flail chest” by DeFreest et al

We read the article ‘‘Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest’’ by DeFreest et al with peaked interest. We would like to commend the authors for conducting one of the largest studies addressing surgical stabilization of rib fractures (SSRF) and the journal for publishing a negative study. We wish to highlight some of the limitations of this study and raise caution interpreting the results. First, the time from admission to SSRF is not reported. One of the goals of SSRF is to minimize physiological compromise. Therefore, SSRF should be considered early (ideally within 24 hours of injury) to mitigate the prolonged hospitalization and decompensation as mentioned in this study. Using SSRF as a ‘‘rescue’’ therapy is going to have an expected negative impact on overall outcomes. Specifically, SSRF done on days 5 to 7, on already ventilated patients, and/or on patients who have failed conservative management will assure longer hospital length of stay (LOS), LOS in the intensive care unit, and a higher incidence of pulmonary complications. The authors readily recognize this and in fact comment in the article that they ‘‘changed practice.’’ We have to assume that their changed practice resulted from recognizing that if SSRF was done earlier, patients did better and would be discharged earlier. Next, the technique of SSRF, including the training in the procedure by the surgeons, is not addressed. Operative technique varies widely, from traditional posterolateral thoracotomy with muscle division and scapular retraction, to minimally invasive, musclesparing techniques.

Computed tomography pulmonary angiography: more than a screening tool for pulmonary embolus.

BACKGROUND Traumatically injured patients have multiple causes for acute respiratory decompensation. We reviewed the use of computed tomography pulmonary angiography (CTPA) in critically injured patients to evaluate the results and impact on patient care. METHODS The charts of trauma patients (age >16 years) admitted to our intensive care unit for greater than 48 hours, who underwent CTPA for acute respiratory decompensation, were reviewed to determine the results of these studies and the effect on patient care. RESULTS We identified 188 patients who underwent CTPA for acute physiologic changes. Pertinent clinical finding were identified in 95% of studies and included atelectasis/collapse (56%), pleural effusion (18%), pneumonia (15%), and pulmonary embolus (18%). These results prompted interventions designed to improve patient outcome. The most frequent interventions were modifications of ventilator therapy (52%), antibiotic therapy (28%), mini-bronchoalveolar lavage (15%), or bronchoscopy (15%). Diagnostic agreement between chest x-ray and CTPA was poor to moderate (κ = 0.013-0.512). CONCLUSIONS Computed tomography pulmonary angiography is valuable in the evaluation of cardiopulmonary deterioration in critically ill traumatically injured patients. Computed tomography pulmonary angiography offers the ability to identify causes of acute physiologic changes not detected using standard chest x-ray. The results of these studies provide insight into the underlying pathophysiology and offer an opportunity to direct subsequent patient care.

Seasonal Variation of Trauma in Western Massachusetts: Fact or Folklore?

Background Previous studies have demonstrated a significant relationship between weather or seasons and total trauma admissions. We hypothesized that specific mechanisms such as penetrating trauma, motor vehicle crashes, and motorcycle crashes (MCCs) occur more commonly during the summer, while more falls and suicide attempts during winter. Methods A retrospective review of trauma admissions to a single Level I trauma center in Springfield, Massachusetts from 01/2010 through 12/2015 was performed. Basic demographics including age, Injury Severity Score (ISS), and length of stay were collected. Linear regression analysis was used to test the association between monthly admission rates and season, year, injury class, and mechanism of injury, and whether seasonal variation trends were different according to injury class or mechanism. Results A total of 8886 admissions had a mean age of 44.6 and mean ISS of 11.9. Regression analysis showed significant seasonal variation in blunt compared with penetrating trauma (p<0.001), MCC (p<0.001), and falls (p=0.002). In addition, seasonal variation differed according to injury class or mechanism. There were significantly lower rates of MCCs in winter compared with all other seasons and conversely higher rates of total falls in winter compared with other seasons. Discussion A significant seasonal variation in blunt trauma, MCC, and falls was observed. This has potential ramifications for resource allocation, including trauma prevention programs geared toward mechanisms of injury with significant seasonal variation. Level of evidence Retrospective Review, Level IV.

Blunt traumatic celiac artery avulsion managed with celiac artery ligation and open aorto-celiac bypass

Traumatic celiac artery injuries are rare and highly lethal with reported mortality rates of 38–62%. The vast majority are caused by penetrating trauma with only 11 reported cases due to blunt trauma (Graham et al., 1978; Asensio et al., 2000, 2002). Only 3 of these cases were complete celiac artery avulsions. Management options described depend upon the type of injury and have included medical therapy with anti-platelet agents or anti-coagulants, endovascular stenting, and open ligation. We report a case of a survivor of complete celiac artery avulsion from blunt trauma managed by open bypass.