Minimally invasive management of thoracic trauma: current evidence and guidelines.

Minimally invasive procedures are being increasingly proposed for trauma. Injuries to the chest wall and/or lung have historically been managed by drainage with a large bore thoracostomy tube, while cardiac injuries have mandated sternotomy. These treatments are associated with significant patient discomfort. Percutaneous placement of small 'pigtail' catheters was initially designed for drainage of simple pericardial fluid. Their use subsequently expanded to drainage of the pleural cavity. The role of pigtail catheters for primary treatment of traumatic pneumothorax and hemopneumothorax has increased, while their use for pericardial fluid after trauma remains controversial. Pericardial windows have alternatively been purposed as a minimally invasive treatment option for possible hemopericardium. The aim of this article is to review the current evidence and guidelines for minimally invasive management of chest trauma.

Proximal protective diverting ostomy following colon anastomosis for penetrating trauma may not be protective: A matched cohort study.

INTRODUCTION: Despite the shift toward liberal primary anastomosis in penetrating colon injuries, some surgeons recommend a protective diverting ostomy (DO) proximal to the anastomosis. This study evaluates the effect of DO on outcomes in patients undergoing colon resection and anastomosis following penetrating trauma. METHODS: The TQIP database (2013-2018) was queried for penetrating colon injuries undergoing colectomy and anastomosis. Patients receiving DO were propensity matched to patients without diverting ostomy (woDO) (1:3). Outcomes were compared between groups. RESULTS: After matching, 89 DO patients were analyzed. The DO group had more surgical site infections (32 â€‹% vs. 21 â€‹%; p â€‹< â€‹0.05) and longer hospital stay (20 [13-27] vs. 15 [9-25]; p â€‹< â€‹0.05) compared to the woDO group. Mortality and unplanned operations were similar between groups. CONCLUSIONS: Diverting ostomy after colon resection and anastomosis is associated with increased infectious complications without decreasing unplanned operations or mortality. Its routine role in penetrating colon trauma needs reassessment.

Immunonutrition with Omega-3 Fatty Acid Supplementation in Severe TBI: Retrospective Analysis of Patient Characteristics and Outcomes.

Background: Early evidence-based medical interventions to improve patient outcomes after traumatic brain injury (TBI) are lacking. In patients admitted to the ICU after TBI, optimization of nutrition is an emerging field of interest. Specialized enteral nutrition (EN) formulas that include immunonutrition containing omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been developed and are used for their proposed anti-inflammatory and pro-immune properties; however, their use has not been rigorously studied in human TBI populations. Methods: A single-center, retrospective, descriptive observational study was conducted at LAC + USC Medical Center. Patients with severe TBI (sTBI, Glasgow Coma Scale score ≤ 8) who remained in the ICU for ≥ 2 weeks and received EN were identified between 2017 and 2022 using the institutional trauma registry. Those who received immunonutrition formulas containing n-3 PUFAs were compared to those who received standard, polymeric EN in regard to baseline characteristics, clinical markers of inflammation and immune function, and short-term clinical outcomes. Results: A total of 151 patients with sTBI were analyzed. Those who received immunonutrition with n-3 PUFA supplementation were more likely to be male, younger, Hispanic/Latinx, and have polytrauma needing non-central nervous system surgery. No differences in clinical markers of inflammation or infection rate were found. In multivariate regression analysis, immunonutrition was associated with reduced hospital length of stay (LOS). ICU LOS was also reduced in the subgroup of patients with polytrauma and TBI. Conclusion: This study identifies important differences in patient characteristics and outcomes associated with the EN formula prescribed. Study results can directly inform a prospective pragmatic study of immunonutrition with n-3 PUFA supplementation aimed to confirm the biomechanistic and clinical benefits of the intervention.

Examining the independent risk factors for withdrawal of life sustaining treatment in trauma patients.

INTRODUCTION: Withdrawal of life sustaining treatment (WLST) occurs when medical intervention no longer benefits a patient's acute goals for care. The incidence of WLST in the trauma patient population is not well understood. The purpose of this study was to examine the incidence and independent risk factors associated with WLST. METHODS: The Trauma Quality Improvement Program (2017-2018) was utilized. Patients arrived without signs of life or without mortality or WLST data were excluded. Demographics, injury data, and outcomes were analyzed. Categorical variables are presented as number (percentage) and continuous variables as median [interquartile range]. WLST and non-WLST patients were compared. Early (<24 h) WLST patients were compared to all other WLST patients. RESULTS: Of 749,754 patients, 35,464 (4.7 %) died. Of these, 19,424 (2.6 %) died after WLST, constituting 54.8 % of all deaths. Median age was 67 [50-79], 67.6 % male, 17,557 (90.4 %) blunt injuries, 11,334 (58.4 %) GCS < 9. Median ISS 26 [17-30]. Median head AIS 4 (3-5). The WLST group had a much higher incidence of elderly (60+) patients (65.1% vs 41.0 %), blunt mechanism of injury (90.4% vs 76.9 %) and hypertension (43.5% vs 26.5 %). Black patients (8.2% vs 19.5 %) and Hispanic patients (7.9% vs 12.2 %) were less likely to undergo WLST. On multivariate analysis, patients 80+ years old (OR 12.939, p < 0.001), GCS < 9 (OR 15.621, p < 0.001), and head AIS = 5, head AIS = 6 (OR 3.886, p < 0.001 and OR 5.283, p < 0.001) were independently associated with WLST. GCS < 9 (OR 4.006, p < 0.001) and penetrating injury (OR 2.825, p < 0.001) were independently associated with early WLST within 24 h. CONCLUSIONS: More than half who die from trauma undergo withdrawal of life sustaining treatment. Elderly patients and those with severe TBI and low GCS scores are at high risk of experiencing withdrawal of life sustaining treatment. Further prospective evaluation is warranted.

Venous Thromboembolism Chemoprophylaxis Compliance in the Surgical Intensive Care Unit.

INTRODUCTION: Early initiation of venous thromboembolism chemoprophylaxis (VTEp) decreases VTE risk in trauma patients in the Surgical Intensive Care Unit (SICU). The frequency and variation of VTEp interruption by different surgical subspecialties in the SICU is incompletely described in the literature. The objective of this study was to examine VTEp compliance in the SICU in terms of uninterrupted VTEp following initiation, both by surgical service and time of year, to identify opportunities for improvement. METHODS: This single-center quality improvement (QI) study examined all SICU patients, which are almost exclusively trauma patients, at our institution (1/2021-04/2022). Exclusions were therapeutic anticoagulation. Type of VTEp, calendar month of SICU stay, perceived indications for interruption, and primary service were collected. RESULTS: Of 5 434 patient days (PD), VTEp was not administered in 1879 (35%). Common reasons for VTEp interruption were ongoing bleeding (n = 964 PD, 51%) and periprocedural status (n = 651 PD, 35%). Periprocedural interruption was highest in July. Acute Care Surgery (ACS) (n = 208 PD, 32%) and Orthopedics (n = 188 PD, 29%) interrupted VTEp most often. ACS most commonly withheld VTEp for second look laparotomies while Orthopedics withheld VTEp for intramedullary nailing or external fixator application. CONCLUSION: Missed VTEp doses occurred most frequently at the beginning of the residency year, with a high percentage held for periprocedural status. Because the necessity of periprocedural VTEp holds is unclear, the appropriateness of these holds and any impact on VTE rates will be assessed as the next steps. In the interim, our findings provide targets for multidisciplinary QI endeavors.

Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated with Increased Risk of Extremity Compartment Syndrome.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used as a temporizing procedure to control intra-abdominal or pelvic bleeding. Theoretically, occlusion of the aorta and the resulting ischemia-reperfusion of the lower extremities may increase the risk of extremity compartment syndrome (CS). To date, no study has addressed systematically the incidence and risk factors of CS following REBOA intervention. The purpose of this study was to address this knowledge gap. METHODS: Adult trauma patients from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database (2016-2019) were included. Patients who received REBOA within 4 h of admission were compared to patients without REBOA after propensity score matching for demographics, vital signs on admission, comorbidities, injury severity of different body regions, pelvic and lower extremity fractures, vascular trauma to the lower extremities, fixation for fractures, angioembolization (AE) for pelvis, preperitoneal pelvic packing (PPP), laparotomy, and venous thromboembolism (VTE) prophylaxis. The primary outcomes were rates of lower extremity CS and fasciotomy and acute kidney injury (AKI). Secondary outcomes included mortality. RESULTS: There were 534 patients who received REBOA matched with 1043 patients without REBOA. Overall, patients in the REBOA group had significantly higher rates of CS than no REBOA patients [5.4% vs 1.1%, p < 0.001, OR: 5.39]. The risk of CS remained significantly higher in the subgroups of patients with or without pelvic or lower extremity fractures, as well as in the subgroup of patients with associated extremity vascular injury [11.2% vs 1.5%, p < 0.001, OR: 8.12].The fasciotomy and AKI rates were significantly higher in the REBOA group (5.8% vs 1.2%, p < 0.001 and 12.9% vs 7.4%, p< 0.001 respectively). CONCLUSION: REBOA use is associated with a higher risk of lower extremity CS, fasciotomy and AKI, especially in patients with associated lower extremity vascular injuries. These complications should be taken into account when considering REBOA use, and close observation for this complication should always be part of the routine monitoring.

REBOA in trauma and the risk of venous thromboembolic complications: A matched-cohort study.

BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used as a damage control procedure in trauma patients. We hypothesized that REBOA increases risk of venous thromboembolic (VTE) complications. METHODS: This was an American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database study. Excluded were transfers, deaths within 24 h, and severe head injuries. Included were trauma patients receiving REBOA within 4 h from arrival. Outcomes in the two groups were compared after using propensity score matching (PSM) for demographic and clinical characteristics, body area abbreviated injury scale, injury severity score, pelvis and lower extremity fractures, angiographic intervention, preperitoneal pelvic packing, pharmacological VTE prophylaxis, laparotomy, laparotomy and specific orthopedic procedures. RESULTS: After PSM, 339 REBOA patients were matched with 663 patients with No REBOA. REBOA patients were significantly more likely to develop pulmonary embolism (PE) (5.3% vs. 2.7%, p = .037) and VTE (14.7% vs. 10.0%, p = .025). CONCLUSION: REBOA is associated with an increased risk of PE and VTE complications. Patients managed with REBOA should receive adequate thromboprophylaxis and be monitored closely for VTE complications.

Worse outcomes with resuscitative endovascular balloon occlusion of the aorta in severe pelvic fracture: A matched cohort study.

BACKGROUND: Severe pelvic fracture is the most common indication for resuscitative endovascular balloon occlusion of the aorta (REBOA). This matched cohort study investigated outcomes with or without REBOA use in isolated severe pelvic fractures. METHODS: Trauma Quality Improvement Program database study, included patients with isolated severe pelvic fracture (AIS≥3), excluded associated injuries with AIS >3 for any region other than lower extremity. REBOA patients were propensity score matched to similar patients without REBOA. Outcomes were mortality and complications. RESULTS: 93 REBOA patients were matched with 279 without. REBOA patients had higher rates of in-hospital mortality (32.3% vs 19%, p = 0.008), higher rates of venous thromboembolism (14% vs 6.5%, p = 0.023) and DVT (11.8% vs 5.4%, p = 0.035). In multivariate analysis, REBOA use was independently associated with increased mortality and venous thromboembolism. CONCLUSIONS: REBOA in severe pelvic fractures is associated with higher rates of mortality, venous thromboembolism.

Gunshot wound versus blunt liver injuries: different liver-related complications and outcomes.

PURPOSE: Severe hepatic injury due to gunshot (GSW) compared to blunt mechanism may have significantly different presentation, management, complications, and outcomes. The aim of this study was to identify the differences. METHODS: Retrospective single-center analysis June 1, 2015-June 30, 2020, included all patients with Grade III-V liver injuries due to GSW or blunt mechanism. Clinical characteristics, severity of injury, liver-related complications (rebleeding, necrosis/abscess, bile leak/biloma, pseudoaneurysm, acute liver failure) and overall outcomes (mortality, hospital length of stay, intensive care unit length of stay, and ventilatory days) were compared. RESULTS: Of 879 patients admitted with hepatic trauma, 347 sustained high-grade injury and were included: 81 (23.3%) due to GSW and 266 (76.7%) due to blunt force. A significantly larger proportion of patients with GSW were managed operatively (82.7 vs. 36.1%, p < 0.001). GSW was associated with significantly more liver-related complications (40.7% vs. 27.4%, p = 0.023), specifically liver necrosis/abscess (18.5% vs. 7.1%, p = 0.003) and bile leak/biloma (12.3% vs. 5.3%, p = 0.028). On subgroup analysis, in patients with grade III injury, the incidence of liver necrosis/abscess and bile leak/biloma remained significantly higher after GSW (13.9% vs. 3.1%, p = 0.008 and 11.1% vs. 2.5%, p = 0.018, respectively). In sub analysis of 88 patients with leading severe liver injuries, GSW had a significantly longer hospital length of stay, ICU length of stay, and ventilator days. CONCLUSION: GSW mechanism to the liver is associated with a higher incidence of liver-related complications than blunt force injury.

Transfusion management in the trauma patient.

PURPOSE OF REVIEW: Transfusion of blood products is lifesaving in the trauma ICU. Intensivists must be familiar with contemporary literature to develop the optimal transfusion strategy for each patient. RECENT FINDINGS: A balanced ratio of red-blood cells to plasma and platelets is associated with improved mortality and has therefore become the standard of care for resuscitation. There is a dose-dependent relationship between units of product transfused and infections. Liquid and freeze-dried plasma are alternatives to fresh frozen plasma that can be administered immediately and may improve coagulation parameters more rapidly, though higher quality research is needed. Trauma induced coagulopathy can occur despite a balanced transfusion, and administration of prothrombin complex concentrate and cryoprecipitate may have a role in preventing this. In addition to balanced ratios, viscoelastic guidance is being increasingly utilized to individualize component transfusion. Alternatively, whole blood can be used, which has become the standard in military practice and is gaining popularity at civilian centers. SUMMARY: Hemorrhagic shock is the leading cause of death in trauma. Improved resuscitation strategy has been one of the most important contemporary advancements in trauma care and continues to be a key area of clinical research.

Prospective evaluation of the selective nonoperative management of abdominal stab wounds: When is it safe to discharge?

BACKGROUND: The optimal observation time required to exclude hollow viscus injury in patients undergoing selective nonoperative management (SNOM) for abdominal stab wounds (SWs) remains unclear. The aim of this study was to determine the safe period of observation required before discharge. METHODS: In this prospective observational study, all patients who sustained an abdominal SW were screened for study inclusion (July 2018 to May 2021). The primary study outcome was time to SNOM failure, defined as the need for surgical intervention after an initial period of observation. RESULTS: During the study period, 256 consecutive patients with an abdominal SW met the study criteria. The mean age was 33 (26-46) years, and 89% were male. Of all patients, 77% had single SW, and 154 (60%) had an anterior abdominal SW (most common site right upper quadrant, 31%). Forty-six (18%) underwent immediate laparotomy because of evisceration (59%), hemodynamic instability (33%), or peritonitis (24%). The remaining 210 patients (82%) were taken for computed tomography scan (n = 208 [99%]) or underwent clinical observation only (n = 2 [<1%]). Of the patients undergoing computed tomography scan, 27 (13%) triggered operative intervention, and 9 (4%) triggered angioembolization. The remaining 174 patients (83%) underwent SNOM. Of these, three patients (2%) failed SNOM and underwent laparotomy: two developed peritonitis at 10 and 20 hours after arrival, respectively, and at laparotomy had small bowel and gastric injuries. The third patient developed increasing leukocytosis but had nontherapeutic laparotomy. CONCLUSION: Selective nonoperative management of stab wounds to the abdomen commonly avoids nontherapeutic operative intervention and its resultant complications. A small percentage of patients will fail SNOM, and therefore, close clinical observation of these patients in hospital is critical. All patients in this series who failed SNOM did so within 24 hours of presentation. Therefore, we recommend a period of 24 hours of close clinical monitoring to exclude a hollow viscus injury before discharge of patients with abdominal stab wounds who do not meet the criteria for immediate operative intervention. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.

Falls from ladders: Injury patterns and outcomes.

BACKGROUND: Our contemporary understanding of the impact of falls from ladders remains limited. The purpose of this study was to examine the injury patterns and outcomes of falls from ladders. Our hypothesis was that age affects both injury type and outcomes. METHODS: The National Trauma Data Bank was queried for all patients who fell from a ladder (January 2007 to December 2017). Participants were stratified into four groups according to age: 15 years or younger, 16 years to 50 years, 51 years to 65 years, and older than 65 years. Univariate and multivariate analyses were performed to compare the injury patterns and outcomes between the groups. RESULTS: A total of 168,227 patients were included for analysis. Median age was 56 years (interquartile range, 45-66 years), 86.1% were male, and median ISS was 9 (interquartile range, 4-13). Increasing age was associated with a higher risk of severe trauma (ISS > 15: 8.8% vs. 13.7% vs. 17.5% vs. 22.0%; p < 0.001). Head injuries followed a U-shaped distribution, with pediatric and elderly patients representing the most vulnerable groups. Overall, fractures were the most common type of injury, in the following order: lower extremity, 27.3%; spine, 24.9%; rib, 23.1%; upper extremity, 20.1%; and pelvis, 10.3%. The overall intensive care unit admission rate was 21.5%; however, it was significantly higher in the elderly (29.1%). In-hospital mortality was 1.8%. The risk of death progressively increased with age with a mortality rate of 0.3%, 0.9%, 1.5%, and 3.6%, respectively ( p < 0.001). Strong predictors of mortality were Glasgow Coma Scale score of 8 or lower on admission (odds ratio, 29.80; 95% confidence interval, 26.66-33.31; p < 0.001) and age >65 years (odds ratio 4.07; 95% confidence interval, 3.535-4.692; p < 0.001). Only 50.8% of the elderly patients were discharged home without health services, 16.5% were discharged to nursing homes, and 15.2% to rehabilitation centers. CONCLUSION: Falls from ladders are associated with considerable morbidity and mortality, especially in the elderly. Head injuries and fractures are common and often severe. An intensified approach to safe ladder use in the community is warranted. LEVEL OF EVIDENCE: Therapeutic/care management; Level III.

Early pharmacologic thromboprophylaxis after splenectomy is associated with better outcomes: A matched cohort study.

BACKGROUND: This study aimed to explore the timing of pharmacologic prophylaxis initiation after trauma splenectomy and the development of venous thromboembolism (VTE). METHODS: Retrospective review of American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2013-2017. Adults (>16 years) with isolated splenic injuries who underwent splenectomy and received pharmacologic VTE prophylaxis were stratified based on timing of initiation of prophylaxis: ≤48 h (EARLY) or > 48 h (LATE) from admission. Patients were matched for demographic and clinical characteristics and outcomes compared. RESULTS: 3631 patients were included. On logistic regression, LATE prophylaxis was associated with DVT (OR 2.317, p < 0.001) and VTE (OR 2.064, p < 0.001). Low molecular weight heparin (LMWH) was protective for DVT (OR 0.621, p = 0.014) and VTE (OR 0.667, p = 0.015). 1196 patients with EARLY prophylaxis were matched with 1196 patients with LATE prophylaxis. VTE and overall complications were significantly higher in the LATE group (7.4% vs. 4.3%, p = 0.001 and 25.8% vs 16.6%, p < 0.001). CONCLUSIONS: Late initiation of VTE prophylaxis is associated with DVT and VTE in post-splenectomy patients, while LMWH is protective.

Destructive colon injuries requiring resection: Is colostomy ever indicated?

BACKGROUND: The management of destructive colon injuries requiring resection has shifted from mandatory diverting stoma to liberal use of primary anastomosis. Various risk criteria have been suggested for the selection of patients for primary anastomosis or ostomy. At our center, we have been practicing a policy of liberal primary anastomosis irrespective of risk factors. The purpose of this study was to evaluate the colon-related outcomes in patients managed with this policy. METHODS: This retrospective study included all colon injuries requiring resection. Data collected included patient demographics, injury characteristics, blood transfusions, operative findings, operations performed, complications, and mortality. RESULTS: A total of 287 colon injuries were identified, 101 of whom required resection, forming the study population. The majority (63.4%) were penetrating injuries. Furthermore, 16.8% were hypotensive on admission, 40.6% had moderate or severe fecal spillage, 35.6% received blood transfusion of >4 U, and 41.6% had Injury Severity Score of >15. At index operation, 88% were managed with primary anastomosis and 12% with colon discontinuity, and one patient had stoma. Damage-control laparotomy (DCL) with temporary abdominal closure was performed in 39.6% of patients. Of these patients with DCL, 67.5% underwent primary anastomosis, 30.0% were left with colon discontinuity, and 2.5% had stoma. Overall, after the definitive management of the colon, including those patients who were initially left in colon discontinuity, only six patients (5.9%) had a stoma. The incidence of anastomotic leaks in patients with primary anastomosis at the index operation was 8.0%, and there was no colon-related mortality. The incidence of colon anastomotic leaks in the 27 patients with DCL and primary anastomosis was 11.1%, and there was no colon-related mortality. Multivariate analysis evaluating possible risk factors identified discontinuity of the colon as independent risk factor for mortality. CONCLUSION: Liberal primary anastomosis should be considered in almost all patients with destructive colon injuries requiring resection, irrespective of risk factors. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Diagnosing penetrating diaphragmatic injuries: CT scan is valuable but not reliable.

BACKGROUND: The diagnosis of penetrating isolated diaphragmatic injuries can be challenging because they are usually asymptomatic. Diagnosis by chest X-ray (CXR) is unreliable, while CT scan is reported to be more valuable. This study evaluated the diagnostic ability of CXR and CT in patients with proven DI. METHODS: Single center retrospective study (2009-2019), including all patients with penetrating diaphragmatic injuries (pDI) documented at laparotomy or laparoscopy with preoperative CXR and/or CT evaluation. Imaging findings included hemo/pneumothorax, hemoperitoneum, pneumoperitoneum, elevated diaphragm, definitive DI, diaphragmatic hernia, and associated abdominal injuries. RESULTS: 230 patients were included, 62 (27%) of which had isolated pDI, while 168 (73%) had associated abdominal or chest trauma. Of the 221 patients with proven DI and preoperative CXR, the CXR showed hemo/pneumothorax in 99 (45%), elevated diaphragm in 51 (23%), and diaphragmatic hernia in 4 (1.8%). In 86 (39%) patients, the CXR was normal. In 126 patients with pDI and preoperative CT, imaging showed hemo/pneumothorax in 95 (75%), hemoperitoneum in 66 (52%), pneumoperitoneum in 35 (28%), definitive DI in 56 (44%), suspected DI in 26 (21%), and no abnormality in 3 (2%). Of the 57 patients with isolated pDI the CXR showed a hemo/pneumothorax in 24 (42%), elevated diaphragm in 14 (25%) and was normal in 24 (42%). CONCLUSIONS: Radiologic diagnosis of DI is unreliable. CT scan is much more sensitive than CXR. Laparoscopic evaluation should be considered liberally, irrespective of radiological findings.

Surgical Rib Fixation in Isolated Flail Chest Improves Survival.

BACKGROUND: The presence of severe associated injuries in flail chest complicates the interpretation of outcomes and the role of rib fixation. This study examined the impact of fixation in patients with isolated flail chest. METHODS: All patients diagnosed with flail chest injuries were queried from the National Trauma Data Bank (2016-2017). Patients who died within 72 hours, transferred from an another hospital, or had associated thoracic aortic injuries or significant extrathoracic injuries were excluded. Patients with rib fixation were propensity score matched 1:3 with similar patients treated nonoperatively, and outcomes were evaluated. Multivariate analysis was used to identify independent predictors for mortality and prolonged mechanical ventilation. RESULTS: Of 287,947 patients with rib fractures, there were 12,110 patients (4.2%) with flail chest. After exclusion, 5293 patients with isolated blunt flail chest injuries were included in the analysis. Rib fixation was performed in 575 (10.9%), and 4718 (89.1%) were managed nonoperatively. After matching, the mortality rate was significantly lower in the fixation group (2.0% vs 5.5%, P = .001). On multivariate analysis, rib fixation was associated with improved mortality (odds ratio, 0.355; P = .002). The timing of the operation was not a significant independent risk factor for mortality. However, early fixation (≤72 hours) was associated with a significantly lower need for prolonged ventilation (>7 days). CONCLUSIONS: Operative fixation in patients with isolated flail chest is associated with improved survival and should be considered liberally. The timing of fixation did not affect mortality, but early fixation was associated with a reduced need for prolonged mechanical ventilation.

Motor vehicle crashes in pregnancy: Maternal and fetal outcomes.

BACKGROUND: Motor vehicle crashes (MVCs) are a leading cause of death in pregnant women. Even after minor trauma, there is risk of fetal complications. The purpose of this study was to compare injuries and outcomes in pregnant with matched nonpregnant women after MVC and evaluate the incidence and type of pregnancy-related complications. METHODS: Retrospective study at a Level I trauma center included pregnant MVC patients, admitted 2009 to 2019. Pregnant patients were matched for age, seatbelt use, and airbag deployment with nonpregnant women (1:3). Gestation-related complications included uterine contractions, vaginal bleeding, emergency delivery, and fetal loss. RESULTS: During the study period, there were 6,930 MVC female admissions. One hundred forty-five (2%) were pregnant, matched with 387 nonpregnant. The seat belt use (71% in nonpregnant vs. 73% in pregnant, p = 0.495) and airbag deployment (10% vs. 6%, p = 0.098) were similar in both groups. Nonpregnant women had higher Injury Severity Score (4 vs. 1, p < 0.0001) and abdominal Abbreviated Injury Scale (2 vs. 1, p < 0.001), but a smaller proportion sustained abdominal injury (18% vs. 53%, p < 0.0001). Mortality (1% vs. 0.7%, p = 0.722), need for emergency operation (6% vs. 3%, p = 0.295) or angiointervention (0.3% vs. 0%, p = 0.540), ventilator days (3 vs. 8, p = 0.907), and intensive care unit (4 vs. 4, p = 0.502) and hospital length of stay (2 vs. 2, p = 0.122) were all similar. Overall, 13 (11.1%) patients developed gestation-related complications, most commonly uterine contractions (6.3%), need for emergency delivery (3.5%), and vaginal bleeding (1.4%). CONCLUSION: Most pregnant patients hospitalized for MVC suffered minor injuries. Pregnant women had lower Injury Severity Score and abdominal Abbreviated Injury Scale than matched nonpregnant women. However, there was still a considerable incidence of gestation-related complications. It is imperative that pregnant patients be closely monitored even after minor trauma. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.