Surgical stabilization of rib fractures in the geriatric trauma population is associated with equivalent outcomes to a younger cohort: A propensity matched analysis.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) improves outcomes in chest wall trauma. Geriatric patients are particularly vulnerable to poor outcomes; yet, this population is often excluded from SSRF studies. Further delineating patient outcomes by age is necessary to optimize care for the aging trauma population. METHODS: A retrospective cohort study was conducted examining outcomes among patients aged 40+ for whom an SSRF consult was placed between 2017 and 2022 at a level 1 trauma center. Patients were categorized into geriatric (65+) and adult (40-64), as well as 80 years and older (80+) and 79 and younger (40-79). Patient outcomes were assessed comparing non-operative and operative management of chest wall trauma. Propensity matched analysis was performed to evaluate mortality differences between adult and geriatric patients who did and did not undergo SSRF. RESULTS: A total of 543 patients had an SSRF consult. Of these, 227 were 65+, and 73 were 80+. A total of 129 patients underwent SSRF (24 %). The percentage of patients undergoing SSRF did not vary between 40 and 64 and 65+ (23.7 % and 23.6 %, respectively, p = 0.97) or 40-79 and 80+ (24.0 vs 21.9, p = 0.69). Patients undergoing SSRF had higher chest injury burden and were more likely to require mechanical ventilation and ICU level care on admission. Overall, in-hospital mortality rate was 4.6 %. Among patients who underwent SSRF, mortality rate did not significantly differ between 65+ and 40-64 (7.8% vs 2.7 %, p = 0.18) or 80+ and 40-79 (6.3% vs 4.6 %, p = 0.77). This remained true in propensity matched analysis. CONCLUSION: Geriatric and octogenarian patients with rib fractures underwent SSRF at similar rates and achieved equivalent outcomes to their younger counterparts. SSRF did not differentially affect mortality outcomes based on age group in propensity matched analysis. SSRF is safe for geriatric patients including octogenarians.

Intercostal nerve cryoablation during surgical stabilization of rib fractures decreases post-operative opioid use, ventilation days, and intensive care days.

BACKGROUND: Intercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF). METHODS: SSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation. RESULTS: 241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05). CONCLUSION: Intercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications.

Acute Care Surgeons Spend More Time than General Surgeons on the Electronic Health Record (EHR).

BACKGROUND: The paradigm of Acute Care Surgery (ACS) emerged in response to decreasing operative opportunities for trauma surgeons and increasing need for surgical coverage in disciplines to which the expertise of trauma surgeons naturally extends. While the continued evolution of this specialty remains largely beneficial, unintended consequences may have arisen along the way. One aspect of ACS that remains to be thoroughly investigated is the impact of the electronic health record (EHR). The purpose of this study is to objectively quantify EHR usage for ACS and compare it to other general surgery specialties. METHODS: EHR user data were collected for fifteen ACS attendings and thirty-seven general surgery attendings from October 2014 to September 2019. Comparative analysis was conducted using two-tailed t-tests. Subgroup analysis was conducted for subspecialties included in the general surgery group. RESULTS: ACS attendings opened almost 3 times as many charts as general surgery attendings per month (180 vs 64 charts/month, P < .0001), and ultimately spent more time on the EHR as a result (10 vs 6.4 hours/month, P < .0001). Documentation was the most time consuming EHR task for both groups. Although ACS attendings spent less overall time per patient chart, the proportion of time spent on certain EHR tasks was similar to that of general surgery colleagues. DISCUSSION: The EHR imposes a disproportionate burden on ACS attendings compared to their general surgery counterparts, and additional study is warranted to improve usage. EHR usage burden has workforce implications for trainees considering a career in ACS.

Multimodal analgesia reduces opioid requirements in trauma patients with rib fractures.

BACKGROUND: Rib fractures are common in trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is essential to avoid the complications associated with rib fractures. Opioids are frequently used for analgesia in these patients. This study compared the effect of a multimodal pain regimen (MMPR) on inpatient opioid use and outpatient opioid prescribing practices in adult trauma patients with rib fractures. STUDY DESIGN: A pre-post cohort study of adult trauma patients with rib fractures was conducted at a Level I trauma center before (PRE) and after (POST) implementation of an MMPR. Patients on long-acting opioids before admission and those on continuous opioid infusions were excluded. Primary outcomes were oral opioid administration during the first 5 days of hospitalization and opioids prescribed at discharge. Opioid data were converted to morphine milligram equivalents (MMEs). RESULTS: Six hundred fifty-three patients met inclusion criteria (323 PRE, 330 POST). There was a significant reduction in the daily MME during the second through fifth days of hospitalization; and the average inpatient MME over the first five inpatient days (23 MME PRE vs. 17 MME POST, p = 0.0087). There was a significant reduction in the total outpatient MME prescribed upon discharge (322 MME PRE vs. 225 MME POST, p = 0.006). CONCLUSION: The implementation of an MMPR in patients with rib fractures resulted in significant reduction in inpatient opioid consumption and was associated with a reduction in the quantity of opiates prescribed at discharge. LEVEL OF EVIDENCE: Therapeutic/Care Management; level IV.

Attention to detail: A dedicated rib fracture consultation service leads to earlier operation and improved clinical outcomes.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has been correlated with improved outcomes, including decreased length of stay (LOS). We hypothesized that an SSRF consultation service would increase the frequency of SSRF and improve outcomes. METHODS: A prospective observational study was performed to compare outcomes before and after implementing an SSRF service. Primary outcome was time from admission to surgery; secondary outcomes included LOS, mortality and morphine milligram equivalents (MME) prescribed at discharge. RESULTS: 1865 patients met consultation criteria and 128 patients underwent SSRF. Mortality decreased (6.3% vs. 3%) and patients were prescribed fewer MME at discharge (328 MME vs. 124 MME) following implementation. For the operative cohort, time from admission to surgery decreased by 1.72 days and ICU LOS decreased by 2.6 days. CONCLUSION: Establishment of an SSRF service provides a mechanism to maximize capture and evaluation of operative candidates, provide earlier intervention, and improve patient outcomes. Additional study to determine which elements and techniques are most beneficial is warranted. LEVEL OF EVIDENCE: III.

Maximizing the Calm before the Storm: Tiered Surgical Response Plan for Novel Coronavirus (COVID-19).

The novel coronavirus (COVID-19) was first diagnosed in Wuhan, China in December 2019 and has now spread throughout the world, being verified by the World Health Organization as a pandemic on March 11. This had led to the calling of a national emergency on March 13 in the US. Many hospitals, healthcare networks, and specifically, departments of surgery, are asking the same questions about how to cope and plan for surge capacity, personnel attrition, novel infrastructure utilization, and resource exhaustion. Herein, we present a tiered plan for surgical department planning based on incident command levels. This includes acute care surgeon deployment (given their critical care training and vertically integrated position in the hospital), recommended infrastructure and transfer utilization, triage principles, and faculty, resident, and advanced care practitioner deployment.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Hemorrhagic Shock.

This clinical practice guideline (CPG) reviews the range of accepted management approaches to profound shock and post-traumatic cardiac arrest and establishes indications for considering Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a hemorrhage control adjunct. The specific management approach - within the parameters of mission, resources, and tactical situation - will depend on the casualty's physical location, mechanism and pattern of injury, and the experience level of the surgeon. The optimal management strategy is best determined by the surgeon at the bedside.

Short-Term Outcomes and Complications of Damage Control and Definitive Laparotomy in Deployed Combat Environments: 2002 to 2011.

INTRODUCTION: Damage control laparotomy (DCL) in an austere environment is an evolving surgical modality. METHODS: A retrospective evaluation of all patients surviving 24 hours who underwent a laparotomy from 2002 to 2011 in Iraq and Afghanistan was performed. DCL was defined as a patient undergoing laparotomy at two distinct North American Treaty Organization (NATO) Role 2 or 3 medical treatment facilities (MTFs); a NATO Roles 2 and 3 MTFs, and/or having the International Classification of Diseases, 9th Revision, Clinical Modification procedure code 54.12, for reopening of recent laparotomy site. Definitive laparotomy (DL) was defined as patients undergoing one operative procedure at one NATO Role 2 or 3 MTF. Demographic data including injury severity scores, hematological transfusion, mortality, intraperitoneal or retroperitoneal operative interventions, and complications were compared. RESULTS: DCL composed of 26.5% (n = 331) of all 1,248 laparotomies performed between March 2002 and September 2011. Total intra-abdominal, acute respiratory distress syndrome, and thromboembolic complications for DCL versus DL were 8.5% and 5.6% (p = 0.07), 2.1% and 0.8% (p = 0.06), and 1.5% and 0.7% (p = 0.17), respectively. Theater discharge mortality from DCL and DL were 1.5% (n = 5), and 1.4% (n = 13) (p = 0.90), respectively. CONCLUSIONS: In conclusion, excluding deaths with the first 24 hours, DCL and DL had comparable mortality and complication rates at NATO Roles 2 and 3 MTFs.

Prospective Evaluation of Weight-Based Prophylactic Enoxaparin Dosing in Critically Ill Trauma Patients: Adequacy of AntiXa Levels Is Improved.

Venous thromboembolism (VTE) is a leading cause of death in multisystem trauma patients; the importance of VTE prevention is well recognized. Presently, standard dose enoxaparin (30 mg BID) is used as chemical prophylaxis, regardless of weight or physiologic status. However, evidence suggests decreased bioavailability of enoxaparin in critically ill patients. Therefore, we hypothesized that a weight-based enoxaparin dosing regimen would provide more adequate prophylaxis (as indicated by antifactor Xa levels) for patients in our trauma intensive care unit (TICU).These data were prospectively collected in TICU patients admitted over a 5-month period given twice daily 0.6 mg/kg enoxaparin (actual body weight). Patients were compared with a historical cohort receiving standard dosing. Anti-Xa levels were collected at 11.5 hours (trough, goal ≥ 0.1 IU/mL) after each evening administration. Patient demographics, admission weight, dose, and daily anti-Xa levels were recorded. Patients with renal insufficiency or brain, spine, or spinal cord injury were excluded. Data were collected from 26 patients in the standard-dose group and 37 in the weight-based group. Sixty-four trough anti-Xa measurements were taken in the standard dose group and 74 collected in the weight-based group. Evaluating only levels measured after the third dose, the change in dosing of enoxaparin from 30 to 0.6 mg/kg resulted in an increased percentage of patients with goal antifactor Xa levels from 8 per cent to 61 per cent (P < 0.0001). Examining all troughs, the change in dose resulted in an increase in patients with a goal anti-Xa level from 19 to 59 per cent (P < 0.0001). Weight-based dosing of enoxaparin in trauma ICU patients yields superior results with respect to adequate anti-Xa levels when compared with standard dosing. These findings suggest that weight-based dosing may provide superior VTE prophylaxis in TICU patients. Evaluation of the effects of this dosing paradigm on actual VTE rate is ongoing at our institution.

Stapled versus hand-sewn anastomoses in emergency general surgery: a retrospective review of outcomes in a unique patient population.

BACKGROUND: Recent studies have identified unique clinical and physiologic characteristics of emergency general surgery (EGS) patients and called for outcomes data in this population. There are no data in the US literature analyzing the impact of technique on anastomotic failure rates in EGS patients. The purpose of the current study was to compare outcomes of hand-sewn (HS) versus stapled (ST) bowel anastomoses in EGS patients. METHODS: A retrospective chart review of all patients admitted by our EGS service undergoing bowel resection for emergent indications from January 2007 to July 2011 was performed. Time from surgery to diagnosis of anastomotic failure was recorded as were the diagnostic modality and treatment of each anastomotic failure. Specific data on damage-control techniques, if used, were also collected. RESULTS: There were 100 HS (43%), and 133 ST (57%) anastomoses in 231 patients. Operative times were shorter in ST anastomosis technique (205 minutes for HS vs. 193 minutes for ST, p = 0.02). Anastomotic failures were identified in 26 patients (11%) and were significantly higher in the ST group than the HS group (15.0% vs. 6.1%, p = 0.003). A multivariate logistic regression analysis, controlling for age and preoperative nutritional status, revealed ST technique to be an independent risk factor for anastomotic failure (odds ratio, 2.65; 95% confidence interval, 1.08-6.50; p = 0.034). CONCLUSION: Anastomotic failures are more than twice as likely with ST than HS anastomoses in the EGS population. This is true even when controlling for markers of preoperative nutrition and demographics. These data suggest that the HS anastomosis should be the preferred method of reconstruction after bowel resection in EGS patients.

Case report of probable desert black snake envenomation in 22-year-old male causing profound weakness and respiratory distress.

We describe a case of a 22-year-old male who presented to our facility 1 hour after a snake bite, which he identified as the desert black snake. He presented with severe weakness and respiratory distress. He was treated with polyvalent antivenom and observed in the Intensive Care Unit (ICU) with resolution of his respiratory symptoms. He developed paresthesias locally around his wound and later complained of diplopia. Two days later, he had total resolution of his symptoms. This is one of the only clinical reports of neurotoxic effects after Walterinnesia morgani envenomation.