Anatomy of the interchondral joints and the effects on mobility of ribs.

BACKGROUND: Variations in the anatomy of the anterior rib cage and costal margin have been observed. We sought to evaluate the location of interchondral joints and evaluate their effect on mobility of the rib cage. METHODS: Cadaveric dissections were performed to evaluate the anatomy of the anterior ribs and the composition of the costal margin. Experienced chest wall surgeons and anatomists evaluated this anatomy through a standardized dissection and assessment. The presence of interchondral joints, and morphology and mobility of ribs were quantified. In addition, the movement and interactions of the ribs with upward pressure on the costal margin at the tip of the 10th rib were assessed. RESULTS: Twenty-eight cadavers were evaluated bilaterally. In all patients, the first rib attached to the manubrium, the second rib attached to the sternal/manubrial junction, and ribs 3 to 6 attached directly to the sternum. Interchondral joints were present between ribs 4/5 in 0%, 5/6 in 35%, 6/7 in 96%, and 7/8 in 96%. The eighth/ninth ribs had free tips in 58% and 92%, respectively, and 10th rib was floating in 46%. Upward pressure on the costal margin resulted in compression of the ribs up to, on average, the 5.7 ± 0.6 rib with no compression above this level. This level corresponded to the rib interspace just above the most superior interchondral joint in 98% of evaluation. The transmission of these upward forces demonstrated an articulation of the ribs at the costal cartilage-sternal junction in the lower ribs. CONCLUSION: Bridging interchondral joints are common between ribs 5 to 8 and participate in distributing forces from the costal margin across the chest wall. Upward forces at the costal margin are transmitted across the lower rib cage and result in increased mobility of the lower half of the ribs. The eighth/ninth ribs often have mobile tips, and the 10th is often a floating rib. LEVEL OF EVIDENCE: Diagnostic Test; Level II.

Blood on the drapes: A multispecialty comparison of blood spill estimates.

INTRODUCTION: Estimated blood loss (EBL) is an important part of the perioperative process. This project aims to determine the accuracy of perioperative team members to estimate blood volume on drapes and the operating room floor. METHODS: Aliquots of unused human blood were used to create surgical scenarios, and standardized pictures and videos were taken. Physicians, residents, nurses, medical students, and surgical technicians were surveyed and asked to estimate the blood volume for each series. Accuracy and consistency of responses was analyzed. RESULTS: One hundred and forty five responses were recorded: 57 attending physicians, 36 residents, 27 registered nurses, 17 medical students, and seven circulating surgical techs. Median percent error (PE) for all cases was 211.11%, demonstrating a global overestimation of blood volume. PE for the 150 mL images was statistically significantly lower than that of the 50 and 100 mL images. Circulating Surgical Technicians were the most accurate group, with a median PE of 125%, followed closely by Medical Students (PE = 158.33%). The most accurate specialty was Orthopedics (PE = 168.06%). The least accurate groups were Attending Physicians (PE = 286.11%) and General surgery (GSGY) (PE = 327.78%). The most accurate orthopedic surgery and GSGY subspecialties were Hand (PE = 237.64%) and Vascular (PE = 108.33%), respectively. Statistical analyses showed no significant differences by clinical role, surgical specialty, or subspecialty. CONCLUSION: This study demonstrates a global overestimation of blood volume when using the visual method, with improved accuracy at higher volumes. Our findings highlight the limitations of visual estimation methods for EBL.

An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers study (CWIS-CC2).

BACKGROUND: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. METHODS: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded. RESULTS: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF. CONCLUSION: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Characterizing re-triage guidelines: A scoping review of states' rules and regulations.

BACKGROUND: State guidelines for re-triage, or emergency inter-facility transfer, have never been characterized across the United States. METHODS: All 50 states' Department of Health and/or Trauma System websites were reviewed for publicly available re-triage guidelines within their rules and regulations. Communication was made via phone or email to state agencies or trauma advisory committees to obtain or confirm the absence of guidelines where public data was unavailable. Guideline criteria were abstracted and grouped into domains of Center for Disease Control Field Triage Criteria: pattern/anatomy of injury, vital signs, special populations, and mechanisms of injury. Re-triage criteria were summarized across states using median and interquartile ranges for continuous data and frequencies for categorical data. Demographic data of states with and without re-triage guidelines were compared using the Wilcoxon rank sum test. RESULTS: Re-triage guidelines were identified for 22 of 50 states (44%). Common anatomy of injury criteria included head trauma (91% of states with guidelines), spinal cord injury (82%), chest injury (77%), and pelvic injury (73%). Common vital signs criteria included Glasgow Coma Score (91% of states) ranging from 8 to 14, systolic blood pressure (36%) ranging from 90 to 100 mm Hg, and respiratory rate (23%) with all using 10 respirations/minute. Common special populations criteria included mechanical ventilation (73% of states), age (68%) ranging from <2 or >60 years, cardiac disease (59%), and pregnancy (55%). No significant demographic differences were found between states with versus without re-triage guidelines. CONCLUSION: A minority of US states have re-triage guidelines. Characterizing existing criteria can inform future guideline development.

Rib fixation for flail chest physiology and the facilitation of safe prone spinal surgery: illustrative case.

BACKGROUND: Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue. OBSERVATIONS: Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery. LESSONS: Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.

The evolution of a chest wall injury and reconstruction clinic during a pandemic.

BACKGROUND: In 2019, we sought to develop a chest wall injury and reconstruction clinic (CWIRC) to treat patients with chest wall pain and rib fractures. This initiative was fueled by the recognition of an unmet need and evolving research demonstrating improved patient care and experience. We will describe the evolution of this clinic program from an acute care surgery/general surgery (ACS/GS) clinic to a CWIRC. METHODS: We identified outpatient encounters generated from a general surgery clinic staffed by a physician and nurse practitioner team. A retrospective cohort review was performed to identify all outpatient encounters and surgeries associated with these encounters from January 1, 2017, to November 30, 2021. Outpatient and operative work relative value unit (wRVU) production as well as payer mix was compared as the primary outcome. RESULTS: Over this time period, the number of clinic interactions decreased (2017-284 vs. 2021-229). Clinic productivity increased however from 181 wRVUs in 2017 to 295 wRVUs in 2021. The CWIRC patient visits increased from 4% to 70%. In addition, telehealth visits increased from 0% to 23% of encounters. The operative wRVU productivity attributable to outpatient clinic visits increased (2017-253 vs. 2021-591). Combined, the CWIRC resulted in an overall growth of 104% in total wRVUs. The payer mixes for patients with rib diagnosis have a higher number of Blue Cross Blue Shield, Medicare, and Managed Care compared with ACS/GS. The most common diagnosis was rib fracture initial evaluation (37%), rib fracture subsequent encounter (25%), rib pain (24%), and flail chest initial evaluation (4%). CONCLUSION: The initiation of a CWIRC increased wRVU production despite a decrease in clinical encounters. These clinics may produce more wRVUs per encounter than ACS/GS clinics. An underserved population has been identified of chest wall pathology patients presenting for initial evaluation as outpatients. Further investigation into this concept is warranted to serve this population. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures following cardiopulmonary resuscitation: An international, retrospective matched case-control study.

BACKGROUND: The presence of six or more rib fractures or a displaced rib fracture due to cardiopulmonary resuscitation (CPR) has been associated with longer hospital and intensive care unit (ICU) length of stay (LOS). Evidence on the effect of surgical stabilization of rib fractures (SSRF) following CPR is limited. This study aimed to evaluate outcomes after SSRF versus nonoperative management in patients with multiple rib fractures after CPR. METHODS: An international, retrospective study was performed in patients who underwent SSRF or nonoperative management for multiple rib fractures following CPR between January 1, 2012, and July 31, 2020. Patients who underwent SSRF were matched to nonoperative controls by cardiac arrest location and cause, rib fracture pattern, and age. The primary outcome was ICU LOS. RESULTS: Thirty-nine operatively treated patient were matched to 66 nonoperatively managed controls with comparable CPR-related characteristics. Patients who underwent SSRF more often had displaced rib fractures (n = 28 [72%] vs. n = 31 [47%]; p = 0.015) and a higher median number of displaced ribs (2 [P 25 -P 75 , 0-3] vs. 0 [P 25 -P 75 , 0-3]; p = 0.014). Surgical stabilization of rib fractures was performed at a median of 5 days (P 25 -P 75 , 3-8 days) after CPR. In the nonoperative group, a rib fixation specialist was consulted in 14 patients (21%). The ICU LOS was longer in the SSRF group (13 days [P 25 -P 75 , 9-23 days] vs. 9 days [P 25 -P 75 , 5-15 days]; p = 0.004). Mechanical ventilator-free days, hospital LOS, thoracic complications, and mortality were similar. CONCLUSION: Despite matching, those who underwent SSRF over nonoperative management for multiple rib fractures following CPR had more severe consequential chest wall injury and a longer ICU LOS. A benefit of SSRF on in-hospital outcomes could not be demonstrated. A low consultation rate for rib fixation in the nonoperative group indicates that the consideration to perform SSRF in this population might be associated with other nonradiographic or injury-related variables. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

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.

Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR. METHODS: A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able. RESULTS: Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home. CONCLUSION: Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed. LEVEL OF EVIDENCE: Therapeutic, Level V.

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.

A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL).

BACKGROUND: The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with displaced rib fractures in the absence of flail chest. METHODS: Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared. RESULTS: One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02). CONCLUSION: In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest. LEVEL OF EVIDENCE: Therapeutic, level II.

The why and how our trauma patients die: A prospective Multicenter Western Trauma Association study.

BACKGROUND: Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality. METHODS: Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed. RESULTS: One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care. CONCLUSION: Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research. LEVEL OF EVIDENCE: Epidemiologic, level II.

A Novel Surgical Technique for Management of Giant Central Calcified Thoracic Disk Herniations: A Dual Corridor Method Involving Tubular Transthoracic/Retropleural Approach Followed by a Posterior Transdural Diskectomy.

BACKGROUND: Thoracic disk herniations (TDHs) represent only 0.15% to 1.8% of surgically managed disk herniations but have posed a particular challenge to spine surgeons. Numerous surgical approaches have been cited in the literature with varying degrees of success, technical complexity, and complication profiles. OBJECTIVE: To report a case of a combined lateral retropleural and dorsal transdural approach for complex thoracic discectomy. METHODS: In this report, we describe a combined lateral/retropleural and posterior transdural approach for a patient with a giant calcified TDH that was not amenable to safe removal using a single approach. RESULTS: In complex situations such as this, a dual corridor approach allows for improved visualization and maximal resection opportunity and opens up yet another option to address recalcitrant TDH. CONCLUSION: The staged dual corridor approach is safe and represents a further surgical option for extremely difficult TDH.

Pharmacologic Stress Gastropathy Prophylaxis May Not Be Necessary in At-Risk Surgical Trauma ICU Patients Tolerating Enteral Nutrition.

OBJECTIVE: Stress gastropathy is a rare complication of the intensive care unit stay with high morbidity and mortality. There are data that support the concept that patients tolerating enteral nutrition have sufficient gut blood flow to obviate the need for prophylaxis; however, no robust studies exist. This study assesses the incidence of clinically significant gastrointestinal bleeding in surgical trauma intensive care unit (STICU) patients at risk of stress gastropathy secondary to mechanical ventilation receiving enteral nutrition without pharmacologic prophylaxis. DESIGN: A retrospective cohort study of records from 2008 to 2013. SETTING: Adult patients in a single-center STICU were included. PATIENTS: Patients were included if they received full enteral nutrition while on mechanical ventilation. Exclusion criteria were coagulopathy, glucocorticoid use, prior-to-admission acid-suppressive therapy use, direct trauma or surgery to the stomach, failure to tolerate goal enteral nutrition, orders to allow natural death, and deviation from the intervention. INTERVENTION: Pharmacologic stress ulcer prophylaxis was discontinued once enteral nutrition was providing full caloric requirements for patients requiring mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: A total of 200 patients were included. The median age was 42 years, 83.0% were male, and 96.0% were trauma patients. The incidence of clinically significant gastrointestinal bleeding was 0.50%, with a subset analysis of traumatic brain injury patients yielding an incidence of 0.68%. Rates of ventilator-associated pneumonia and Clostridium difficile infection were low at 1.0 case/1000 ventilator days and 0.2 events/1000 patient days, respectively. Hospital all-cause mortality was 2.0%. Cost savings of US$121/patient stay were realized. CONCLUSION: Stress gastropathy is rare in this population. Surgical and trauma patients at risk for stress gastropathy did not benefit from continued pharmacologic prophylaxis once they tolerated enteral nutrition. Pharmacologic prophylaxis may safely be discontinued in this patient population. Further investigation is warranted to determine whether continued prophylaxis after attaining enteral feeding goals is detrimental.

Contemporary management of subclavian and axillary artery injuries-A Western Trauma Association multicenter review.

BACKGROUND: Subclavian and axillary artery injuries are uncommon. In addition to many open vascular repairs, endovascular techniques are used for definitive repair or vascular control of these anatomically challenging injuries. The aim of this study was to determine the relative roles of endovascular and open techniques in the management of subclavian and axillary artery injuries comparing hospital outcomes, and long-term limb viability. METHODS: A multicenter, retrospective review of patients with subclavian or axillary artery injuries from January 1, 2004, to December 31, 2014, was completed at 11 participating Western Trauma Association institutions. Statistical analysis included χ, t-tests, and Cochran-Armitage trend tests. A p value less than 0.05 was significant. RESULTS: Two hundred twenty-three patients were included; mean age was 36 years, 84% were men. An increase in computed tomography angiography and decrease in conventional angiography was observed over time (p = 0.018). There were 120 subclavian and 119 axillary artery injuries. Procedure type was associated with injury grade (p < 0.001). Open operations were performed in 135 (61%) patients, including 93% of greater than 50% circumference lacerations and 83% of vessel transections. Endovascular repairs were performed in 38 (17%) patients; most frequently for pseudoaneurysms. Fourteen (6%) patients underwent a hybrid procedure. Use of endovascular versus open procedures did not increase over the duration of the study (p = 0.248). In-hospital mortality rate was 10%. Graft or stent thrombosis occurred in 7% and graft or stent infection occurred in 3% of patients. Mean follow-up was 1.6 ± 2.4 years (n = 150). Limb salvage was achieved in 216 (97%) patients. CONCLUSION: The management of subclavian and axillary artery injuries still requires a wide variety of open exposures and procedures, especially for the control of active hemorrhage from more than 50% vessel lacerations and transections. Endovascular repairs were used most often for pseudoaneurysms. Low early complication rates and limb salvage rates of 97% were observed after open and endovascular repairs. LEVEL OF EVIDENCE: Prognostic/epidemiologic, level IV.

The role of computed tomographic scan in ongoing triage of operative hepatic trauma: A Western Trauma Association multicenter retrospective study.

BACKGROUND: A subset of patients explored for abdominal injury have persistent hepatic bleeding on postoperative computed tomography (CT) and/or angiography, either not identified or not manageable at initial laparotomy. To identify patients at risk for ongoing hemorrhage and guide triage to angiography, we investigated the relationship of early postoperative CT scan with outcomes in operative hepatic trauma. METHODS: This is a retrospective review of 528 patients with hepatic injury taken to laparotomy without imaging within 6 hours of arrival to six trauma centers from 2007 to 2013, coordinated through the Western Trauma Association multicenter trials group. RESULTS: A total of 528 patients were identified, with a mean age of 31 years, 82% male, and 37% blunt injury; mean (SD) Injury Severity Score (ISS) was 27 (16) and base deficit was -9 (6); in-hospital mortality was 26%. Seventy-three patients died during initial exploration. Of 455 early survivors, 123 (27%) had a postoperative contrast CT scan within 24 hours of laparotomy. CT patients had more common blunt injury, higher ISS, and lower base deficit than those who did not undergo CT. CT identified hepatic contrast extravasation or pseudoaneurysm in 10 patients (8%). Hepatic bleeding on CT was 83% sensitive and 75% specific (likelihood ratio, 3.3) for later positive angiography; negative CT finding was 96% sensitive and 83% specific (likelihood ratio, 5.7) for later negative or not performed angiography. Despite occurring in a more severely injured cohort, performance of early postoperative CT was associated with reduced mortality (odds ratio, 0.16) in multivariate analysis. Blunt mechanism was also a multivariate predictor of mortality (odds ratio, 3.0). CONCLUSION: Early postoperative CT scan after laparotomy for hepatic trauma identifies clinically relevant ongoing bleeding and is sufficiently sensitive and specific to guide triage to angiography. Contrast CT should be considered in the management algorithm for hepatic trauma, particularly in the setting of blunt injury. Further study should identify optimal patient selection criteria and CT scan timing in this population. LEVEL OF EVIDENCE: Care management/therapeutic study, level IV; epidemiologic/prognostic study, level III.

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.