Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes?

BACKGROUND: Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older. METHODS: Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management. RESULTS: Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups. CONCLUSION: Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Can Education and Enhanced Medical Director Oversight Improve Definitive Airway Control in the Prehospital Environment?

BACKGROUND: Endotracheal intubation (ETI) is the most definitive technique for airway management. However, supraglottic airway (SGA) may be used when ETI is not feasible. The purpose of this study was to determine the effect of updated field sedation protocols, simulation teaching, robust Quality Assurance/Continuing Quality Improvement (QA/CQI) program, and enhanced emergency medical services (EMSs) medical director oversight on ETI and SGA usage at a Level 1 trauma center. METHODS: After the transition of EMS directors in May 2016, field sedation protocols were updated, a new QA/CQI was instituted, and multiple teaching and simulation sessions were conducted. A retrospective review of EMS data was conducted on all prehospital airway interventions performed by EMS personnel. Intubations occurring from July 2013 to May 2016 served as controls. Intubations from May 2016 to December 2017 served as the comparison group. Data collected included intubation type/indication, age, and successful or unsuccessful. RESULTS: There were 967 ETI and SGA performed on 84% and 15% of patients, respectively. Success rates were 75% for ETI and 82% for SGA. ETI increased from 83% in the control group to 88% in the study group, and SGA decreased from 16% in the control group to 11% in the study group (P = .029). The success rate for ETI increased by 2% in the study group (P = .539). DISCUSSION: This study showed that definitive airway control could be positively impacted by incorporating education and medical director oversight into EMS training. ETI increased and SGA decreased after implementation.

Wittmann Patch : Superior Closure for the Open Abdomen.

INTRODUCTION: Damage control laparotomy (DCL) is a life-saving surgical technique, but the resultant open abdomen (OA) carries serious morbidity/mortality. Many methods are utilized to manage OAs, but discrepancy exists in distinguishing closure from coverage techniques. We observed a difference in our DCL patient outcomes managed with the Wittmann Patch (WP) closure device versus the more popular ABThera (AB) coverage device. We hypothesized that the WP contributed to an improved fascial closure rate of the OAs after DCL. METHODS: A retrospective review of OAs managed with the AB or WP at our Level 1 trauma center was performed using billing codes to capture DCL patients from 2011 to 2019. Patients were divided into AB alone or WP groups. Major endpoints included primary fascial closure (PFC) and delayed fascial closure (DFC, fascial closure after greater than 7 days). RESULTS: 189 patients were identified as AB and 38 as WP. Rates of death before closure, age, gender, and Injury Severity Score were similar in both groups. PFC = 81%-90% for AB versus WP, respectively. Excluding patients with preexisting hernias PFC = 87%-100% for AB versus WP (P < .05) and DFC = 44%-100% for AB versus WP (P ≤ 0.001). WP had a statistically higher rate of PFC and DFC. There was a decreased incidence of complications in the WP versus AB group. CONCLUSIONS: While not well reported in the peer-reviewed literature, the application of the WP for management of the OA is an active form of pursuing PFC when compared with the AB, a coverage device. Our interinstitutional results have demonstrated superior PFC and DFC rates and fewer complications, in patients managed with the WP compared with the AB.