Chest wall stabilization in a patient with severe TBI: A case report.

INTRODUCTION AND IMPORTANCE: Flail chest is a serious complication that may arise secondary to thoracic trauma and is associated with increased morbidity and mortality. In a flail chest, paradoxical chest movement decreases the functional residual capacity, leading to hypoxia, hypercapnia, and atelectasis. Adequate ventilation, fluid and pain management have classically been the cornerstones to flail chest treatment, with operative fixation being utilized in specific cases. Traumatic brain injury (TBI) has historically been believed to be an absolute contraindication for surgical fixation of rib fractures (SSRF); however, emerging studies have shown a favorable prognosis in select patients who underwent SSRF with severe TBI (Glasgow Coma Scale ≤8). CASE PRESENTATION: A 66-year-old male was brought into the Emergency Department by EMS following a traumatic injury that resulted in multiple rib fractures, spinal fractures, and traumatic brain injury. On hospital day 3, the patient underwent SSRF to repair bilateral flail chest. SSRF stabilized cardiopulmonary physiology, improving this patient's hospital course and avoiding the need for a tracheostomy. Herein, we report the successful use of SSRF in a flail chest patient with severe TBI that improved outcomes without evidence of secondary brain injury. CLINICAL DISCUSSION: TBI is a severe condition that often presents with other injuries. Chest wall injuries (CWI) with concurrent TBI remain a significant challenge for clinicians as one set of injuries may exacerbate the other [10]. Through respiratory physiology and predisposition to pneumonia, CWI may lead to prolonged cerebral hypoxia resulting in secondary brain injury-worsening severe TBI. SSRF improves outcomes in polytrauma patients exhibiting CWI with TBI. CONCLUSION: Surgical management of rib fractures has an essential role in select patients with severe TBI. Further research is warranted to improve our understanding of the complex interplay between the physiology of respiratory mechanics and the neurologic system in the trauma population suffering from TBI.

Surgical stabilization of rib fracture patients versus nonoperative controls treated by a multidisciplinary team in a single institution.

Introduction: Despite promising evidence, surgical stabilization of rib fractures (SSRF) is not ubiquitously offered in all trauma centers. Some centers struggle with patient selection while some struggle due to surgeon comfort with the technique. To address this issue, our trauma center developed a multidisciplinary SSRF approach between orthopedic and trauma surgery. Methods: This retrospective study compared 43 patients who underwent SSRF at a level 1 trauma center with 43 nonoperatively managed controls. Our study Indications were flail chest with >3 segments; non-flail with severe, bi-cortical displacement of >3 contiguous segments. Main outcome measures included mortality, ICU duration, hospital stay LOS, rates of ventilator-associated pneumonia (VAP) and ventilator days. Results: Results of SSRF included decreases in mortality (2% vs 16.3%; p = 0.03) and in ICU duration. Patients with SSRF had a significantly shorter duration in the ICU than the nonoperative group (8.72 vs 14 days; p = 0.013) but a similar hospital duration (LOS mean, 12.81 vs 15.2; p = 0.29). Less patients in the SSRF group developed VAP but the difference was not significant (2% vs 14%, p = 0.055). Discussion: SSRF patient outcomes supported prior evidence. The tandem approach had benefits as surgeons were able to leverage skills and expertise, increase collaboration between services, and complete more difficult reconstructions. Our experience may serve as a model for trauma centers interested in starting a new program or enhancing current service offerings.

Shift Length and Shift Length Preference Among Acute Care Surgeons.

BACKGROUND: Work hour restrictions have been imposed by the Accreditation Council for Graduate Medical Education since 2003 for medical trainees. Many acute care surgeons currently work longer shifts but their preferred shift length is not known. METHODS: The purpose of this study was to characterize the distribution of the current shift length among trauma and acute care surgeons and to identify the surgeons' preference for shift length. Data collection included a questionnaire with a national administration. Frequencies and percentages are reported for categorical variables and medians and means with SDs are reported for continuous variables. A chi-square test of independence was performed to examine the relation between call shift choice and trauma center level (level 1 and level II), age, and gender. RESULTS: Data from 301 surgeons in 42 states included high-level trauma centers. Assuming the number of trauma surgeons in the United States is 4129, a sample of 301 gives the survey a 5% margin of error. The median age was 43 years (M = 46, SD = 9.44) and 33% were female. Currently, only 23.3% of acute care surgeons work a 12-hour shift, although 72% prefer the shorter shift. The preference for shorter shifts was statistically significant. There was no significant difference between call shift length preference and trauma center level, age, or gender. CONCLUSION: Most surgeons currently work longer than 12-hour shifts. Yet, there was a preference for 12-hour shifts indicating there is a gap between current and preferred shift length. These findings have the potential to substantially impact staffing models.

Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial.

BACKGROUND: The frailty index is a known predictor of adverse outcomes in geriatric patients. Trauma-Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients. METHODS: This is a prospective, observational, multi-institutional trial across 17 American College of Surgeons Levels I, II, and III trauma centers. All geriatric trauma patients (65 years and older) presenting during a 3-year period were included. Frailty status was measured within 24 hours of admission using the TSFI (15 variables), and patients were stratified into nonfrail (TSFI, ≤0.12), prefrail (TSFI, 0.13-0.25), and frail (TSFI, >0.25) groups. Outcome measures included index admission mortality, discharge to rehabilitation centers or skilled nursing facilities (rehab/SNFs), and 3-month postdischarge readmissions, fall recurrences, complications, and mortality among survivors of index admission. RESULTS: A total of 1,321 geriatric trauma patients were identified and enrolled for validation of TSFI (nonfrail, 435 [33%]; prefrail, 392 [30%]; frail, 494 [37%]). The mean ± SD age was 77 ± 8 years; the median (interquartile range) Injury Severity Score was 9 (5-13). Overall, 179 patients (14%) had a major complication, 554 (42%) were discharged to rehab/SNFs, and 63 (5%) died during the index admission. Compared with nonfrail patients, frail patients had significantly higher odds of mortality (adjusted odds ratio [aOR], 1.93; p = 0.018), major complications (aOR, 3.55; p < 0.001), and discharge to rehab/SNFs (aOR, 1.98; p < 0.001). In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge ( p < 0.05). CONCLUSION: External applicability of the TSFI (15 variables) was evident at a multicenter cohort of 17 American College of Surgeons trauma centers in geriatric trauma patients. The TSFI emerged as an independent predictor of worse outcomes, both in the short-term and 3-month postdischarge. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.