Flail chest injury-changing management and outcomes.

PURPOSE: The purpose of this study was to assess trends in management of flail chest injuries over time and to determine impact on patient outcomes. METHODS: A retrospective review of data from a prospectively collated database of all trauma patients admitted to a level 1 trauma service in Victoria was conducted. All trauma patients admitted to the hospital between July 2008 and June 2020 with an Abbreviated Injury Scale (AIS) code for flail chest injury were included. RESULTS: Our study included 720 patients, mean age was 59.5 ± 17.3 years old, and 76.5% of patients were male. Length of ICU stay decreased on average by 9 h each year. Regional anaesthesia use increased by 15% per year (0% in 2009 to 36% in 2020) (p < 0.001). Surgical stabilisation of rib fractures increased by 16% per year (2.9% in 2009 to 22.3% in 2020) (p = 0.006). The use of invasive ventilation decreased by 14% per year (70% in 2008 to 27% in 2020) (p < 0.001), and invasive ventilation time decreased by 8 h per year (p = 0.007). CONCLUSION: Over the past decade, we have seen increasing rates of regional anaesthesia and surgical rib fixation in the management of flail chest. This has resulted in lower requirements for and duration of invasive mechanical ventilation and intensive care unit stay but has not impacted mortality in this patient cohort.

Regional anaesthesia for rib fractures: A pilot study of serratus anterior plane block.

OBJECTIVE: Rib fractures are not only painful but are associated with morbidity and mortality, especially in older patients. The serratus anterior plane block (SAPB) is a plane block distant from major neurovascular bundles and may provide anaesthesia to a substantial area of the hemithorax. This pilot study was designed to assess if the SAPB can be safely and efficiently incorporated to the trauma reception workflow of an adult, level 1 trauma centre. METHODS: A convenience sample of 20 adult patients with at least two or more unilateral rib fractures received a SAPB performed by an emergency physician in addition to their standard analgesic regime. Time to perform the procedure, the number of attempts and complications were recorded as feasibility measures. Secondary outcome was the safety of the block. Numerical pain scores at pre-determined time points over 4 h, the diagnosis of hospital-acquired pneumonia, hospital length of stay and mortality at hospital discharge were collected to provide pilot data on effectiveness. RESULTS: The median time to perform the procedure was 5.5 (interquartile range 4.6-10) mins with a range of 2-10.5 min. Most (16; 80%) SAPBs were completed in a single attempt. There were no documented complications. Median pain scores reduced from 6.5 (6-8) and were maintained at 3 (2-5) at 4 h after the SAPB. CONCLUSIONS: The present study demonstrated the feasibility of ultrasound-guided SAPB among patients with multiple rib fractures in the ED. No complications were observed. Further prospective evaluation of analgesic effects in a larger cohort is indicated.

Impact of infarct size on clinical and echocardiographic outcome in patients undergoing nonsurgical septal reduction therapy.

BACKGROUND: Nonsurgical septal reduction therapy (NSRT) with ethanol improves clinical and hemodynamic parameters in patients with symptomatic hypertrophic obstructive cardiomyopathy. The purpose of this study was to examine the impact of infarct size induced by ethanol injection on clinical and echocardiographic outcome after the procedure. METHODS AND RESULTS: The first 261 consecutive patients were included. The mean age was 51 +/- 6 years, and 127 patients were women. The mean creatine kinase (CK) after NSRT was 1411 +/- 653 units. Men had larger infarcts than women (P =.0028). Injecting ethanol as a bolus (P <.001), injecting >1 septal branch (P <.001), or injecting >3 cc of ethanol per septal branch (P <.001) were all determinants of infarct size. When the patients were divided into 4 groups according to peak CK, the New York Heart Association dyspnea score after NRST, the septal thickness, and left ventricular outflow tract gradient were more significantly reduced in patients with peak CK >1000 U/dL compared to those with peak CK <1000 U/dL. Patients with peak CK >1500 U/dL had a significant drop in left ventricular ejection fraction at 6 weeks (70 +/- 6 vs 63 +/- 6, P =.035). CONCLUSION: An average size infarct (peak CK 1000-1500 U/dL) seems to lead to the optimal outcome after NSRT.