How Many Screws to Use: A Report of Outcomes After Surgical Stabilization of Rib Fractures Where less than the Manufacturer Recommended Screw Number Were Applied.

Surgical stabilization of rib fractures in an effective technique for the management of bony thoracic trauma. However, rib fractures location or morphology may make the placement of the recommended 6 screws impossible. A retrospective analysis of patients receiving SSRF at our facility from 2009-2019 identified cases where less than the recommended screw placement was used. Respiratory complications and hardware integrity were analyzed using follow-up imaging and examinations when available. A total of 62 patients were identified that used less than the recommended number of screws. The majority of these were in the lateral and posterior chest wall positions. 1 pleural effusion, no pneumothoraces, deaths, or hardware dislodgments were identified. While the authors do not advocate for the routine deviation from manufacture recommendations, we concluded that in select circumstances, adequate fixation can be achieved with less than 6 screws across a plated fracture.

Surgical Stabilization of Rib Fractures Improves Outcomes in the Geriatric Patient Population.

INTRODUCTION: Rib fractures in the ≥65-year-old population have been shown to strongly influence mortality and pneumonia rates. There is a growing body of evidence demonstrating improvements in the geriatric patient's survival statistics and respiratory performances after surgical stabilization of rib fractures (SSRF). We have observed a strong survival and complication avoidance trend in geriatric patients who undergo SSRF. The purpose of our study was to evaluate the outcomes of geriatric patients with rib fractures treated with SSRF compared to those who only receive conservative therapies. METHODS: We performed a retrospective review of our trauma registry analyzing outcomes of patients ≥65 years with rib fractures. Patients admitted from 2015 to 2019 receiving SSRF (RP group) were compared to a nonoperative controls (NO group) admitted during the same time. Bilateral fractures were excluded. Independent variables analyzed = ISS, mortalities, hospital days, ICU days, pleural space complications, and readmissions. Follow-up was 60 days after discharge. Group comparison was performed using Kolmogorov-Smirnov, Shapiro-Wilk, and Mann-Whitney U tests. RESULTS: 257 patients were analyzed: 172 in the NO group with mean age of 75 (65-10) and 85 in the RP group with mean age of 74 (65-96). Mean ISS = 13 (1-38) for the NO group and 20 (9-59) for the RP group (P < .001). Mean hospital days = 8 (1-39) and 15 (3-49) in NO and RP groups, respectively. Mean ICU days = 10 (1-32) and 8 (1-11) in NO and RP groups, respectively. Deaths, pneumonia, readmissions, and pleural effusions in the NO group were statistically significant (P < .01). Analysis of complications revealed 4 RP patients (4.7%) with respiratory complications out to 60 days and 65 NO patients (37.8%) (P < .001). CONCLUSIONS: Surgical stabilization of rib fractures appears to be associated with a survival advantage and an avoidance of respiratory-related complications in the ≥65-year-old patient population.

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury.

PURPOSE: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients. METHODS: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern. RESULTS: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034). CONCLUSION: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI).

BACKGROUND: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI. METHODS: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI. RESULTS: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034). CONCLUSION: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI. LEVEL OF EVIDENCE: Therapeutic, level IV.

Ultrasound in trauma resuscitation and critical care with hemodynamic transesophageal echocardiography guidance.

BACKGROUND: Volume replacement strategies and resuscitation endpoints of therapy in the critical ill or injured patient continues to be a heavily debated topic despite decades of research and the ever evolving technologies that provide for alternate methods of monitoring. Hemodynamic transesophageal echocardiography (hTEE), refined for the use in the intensive care unit (ICU), allows for direct visualization of cardiac filling and function, enabling real-time guidance in the resuscitation of critically ill patients. The disposable, 17F hTEE probe can remain indwelling for up to 72 hours, providing continuous, unobstructed assessments of cardiac activity via the transgastric short axis, midesophageal four chamber, and superior vena cava views. With such, preload and contractility, ventricular size and function, and volume responsiveness can be accurately evaluated and trended for change over time. Hemodynamic transesophageal echocardiography as a monitoring modality is becoming more pervasive in ICUs on a worldwide scale, allowing for real-time visualization of resuscitation and its therapeutic effects, a better understanding of resuscitation effects on individual patients, a more rapid conclusion to patient's resuscitation needs and provides the physician more confidence and patience in guiding complex volume resuscitations. RESULTS: This presentation will focus on discussing practical applications of the hTEE system and its benefits in critical care management. We will review four patients at our facility admitted to the ICU due to hemodynamic instability of varying etiologies that required volume resuscitation. With the videos, we will demonstrate how hTEE can guide patient therapy, often counter-intuitively, in the critically ill using the three basic cardiac views. Specific scenarios and hTEE videos include: (1) volume resuscitation in Acute Respiratory Distress Syndrome (ARDS), (2) volume resuscitation guided by hTEE, (3) underresuscitation in a "routine" trauma case, and (4) deescalation of therapy by weaning of high-dose vasopressors using hTEE monitoring. CONCLUSION: Hemodynamic transesophageal echocardiography is an excellent hemodynamic monitoring modality for the intensivist and has many practical applications in the management of the critical ill or injured patients. Hemodynamic transesophageal echocardiography has demonstrated that patient's resuscitation needs are often underestimated and that a more tailored approach to volume delivery is achievable, a particular benefit in the older and more comorbid patient. Future applications of hTEE include CRRT volume management, organ donor hemodynamic optimization, and postresuscitation monitoring in trauma patient requiring massive transfusion protocol. These videos demonstrate examples of the benefits of real-time cardiac monitoring, which allowed for guided resuscitation and improved patient outcomes. LEVEL OF EVIDENCE: Procedures and techniques, level IV.

Geriatric chest wall injury: is it time for a new sense of urgency?

Geriatric trauma has become an increasingly recognized management concern for trauma centers, and hospitals alike, on a national scale. The population of the United States is aging, as life expectancy rates have demonstrated a steady climb to an average of 78.8 years of expected life. With pervasive efforts of medical screening, prevention and chronic medical condition management, more elderly people will lead more active lifestyles and will be more predisposed to injury. As best practice guidelines specific for the geriatric trauma population have yet to be developed, many researchers have identified management strategies that have offset complications and mortality rates inherent to this patient population after injury. The impact of rib fractures in the 65-year and older patient population has been well documented, as have the mortality and pneumonia rates yet, historically, little attention has been directed to curtailing these adverse outcomes with more advanced treatment options. With the advent of rib plating for rib fracture fixation and chest wall stabilization, the practice paradigm for rib fracture management is shifting, as a viable operative intervention now exists. In this review, we focus on the characteristics of the geriatric trauma patient, areas of management where improvement opportunities have been identified, chest wall injury in the elderly patient, rib plating as a treatment option and offer our data to facilitate a better understanding of rib plating's impact in the geriatric trauma patient.