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.

What is the value of 3D virtual reality in understanding acetabular fractures?

BACKGROUND: Acetabular fractures are difficult to classify owing to the complex three-dimensional (3D) anatomy of the pelvis. 3D printing helps to understand and reliably classify acetabular fracture types. 3D-virtual reality (VR) may have comparable benefits. Our hypothesis is that 3D-VR is equivalent to 3D printing in understanding acetabular fracture patterns. METHODS: A total of 27 observers of various experience levels from several hospitals were requested to classify twenty 3D printed and VR models according to the Judet-Letournel classification. Additionally, surgeons were asked to state their preferred surgical approach and patient positioning. Time to classify each fracture type was recorded. The cases were randomized to rule out a learning curve. Inter-observer agreement was analyzed using Fleiss' kappa statistics (κ). RESULTS: Inter-observer agreements varied by observer group and type of model used to classify the fracture: medical students: 3D print (κ = 0.61), VR (κ = 0.41); junior surgical residents: 3D print (0.51) VR (0.54); senior surgical residents: 3D print (0.66) VR (0.52); junior surgeons: 3D print (0.56), VR (0.43); senior surgeons: 3D print (κ = 0.59), VR (κ = 0.42). Using 3D printed models, there was more agreement on the surgical approach (junior surgeons κ = 0.23, senior surgeons κ = 0.31) when compared with VR (junior surgeons κ = 0.17, senior surgeons 0.25). No difference was found in time used to classify these fractures between 3D printing and VR for all groups (P = 1.000). CONCLUSIONS: The Judet-Letournel acetabular classification stays difficult to interpret; only moderate kappa agreements were found. We found 3D-VR inferior to 3D printing in classifying acetabular fractures. Furthermore, the current 3D-VR technology is still not practical for intra-operative use.

Fast track surgery versus conventional recovery strategies for colorectal surgery.

BACKGROUND: In recent years the Enhanced Recovery after Surgery (ERAS) postoperative pathway in (ileo-)colorectal surgery, aiming at improving perioperative care and decreasing postoperative complications, has become more common. OBJECTIVES: We investigated the effectiveness and safety of the ERAS multimodal strategy, compared to conventional care after (ileo-)colorectal surgery. The primary research question was whether ERAS protocols lead to less morbidity and secondary whether length of stay was reduced. SEARCH STRATEGY: To answer the research question we entered search strings containing keywords like "fast track", "colorectal and surgery" and "enhanced recovery" into major databases. We also hand searched references in identified reviews concerning ERAS. SELECTION CRITERIA: We included published randomised clinical trials, in any language, comparing ERAS to conventional treatment in patients with (ileo-) colorectal disease requiring a resection. RCT's including at least 7 ERAS items in the ERAS group and no more than 2 in the conventional arm were included. DATA COLLECTION AND ANALYSIS: Data of included trials were independently extracted by the reviewers. Analyses were performed using "REVMAN 5.0.22". Data were pooled and rate differences as well as weighted mean differences with their 95% confidence intervals were calculated using either fixed or random effects models, depending on heterogeneity (I(2)). MAIN RESULTS: 4 RCTs were included and analysed. Methodological quality of included studies was considered low, when scored according to GRADE methodology. Total numbers of inclusion were limited. The trials included in primary analysis reported 237 patients, (119 ERAS vs 118 conventional). Baseline characteristics were comparable. The primary outcome measure, complications, showed a significant risk reduction for all complications (RR 0.50; 95% CI 0.35 to 0.72). This difference was not due to reduction in major complications. Length of hospital stay was significantly reduced in the ERAS group (MD -2.94 days; 95% CI -3.69 to -2.19), and readmission rates were equal in both groups. Other outcome parameters were unsuitable for meta-analysis, but seemed to favour ERAS. AUTHORS' CONCLUSIONS: The quantity and especially quality of data are low. Analysis shows a reduction in overall complications, but major complications were not reduced. Length of stay was reduced significantly. We state that ERAS seems safe, but the quality of trials and lack of sufficient other outcome parameters do not justify implementation of ERAS as the standard of care. Within ERAS protocols included, no answer regarding the role for minimally invasive surgery (i.e. laparoscopy) was found. Furthermore, protocol compliance within ERAS programs has not been investigated, while this seems a known problem in the field. Therefore, more specific and large RCT's are needed.

A prospective cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track multimodal management, for surgical patients with colon carcinomas (TAPAS study).

BACKGROUND: The present developments in colon surgery are characterized by two innovations: the introduction of the laparoscopic operation technique and fast recovery programs such as the Enhanced Recovery After Surgery (ERAS) recovery program. The Tapas-study was conceived to determine which of the three treatment programs: open conventional surgery, open 'ERAS' surgery or laparoscopic 'ERAS' surgery for patients with colon carcinomas is most cost minimizing? METHOD/DESIGN: The Tapas-study is a three-arm multicenter prospective cohort study. All patients with colon carcinoma, eligible for surgical treatment within the study period in four general teaching hospitals and one university hospital will be included. This design produces three cohorts: Conventional open surgery is the control exposure (cohort 1). Open surgery with ERAS recovery (cohort 2) and laparoscopic surgery with ERAS recovery (cohort 3) are the alternative exposures. Three separate time periods are used in order to prevent attrition bias. Primary outcome parameters are the two main cost factors: direct medical costs (real cost price calculation) and the indirect non medical costs (friction method). Secondary outcome parameters are mortality, complications, surgical-oncological resection margins, hospital stay, readmission rates, time back to work/recovery, health status and quality of life. Based on an estimated difference in direct medical costs (highest cost factor) of 38% between open and laparoscopic surgery (alfa = 0.01, beta = 0.05), a group size of 3 x 40 = 120 patients is calculated. DISCUSSION: The Tapas-study is three-arm multicenter cohort study that will provide a cost evaluation of three treatment programs for patients with colon carcinoma, which may serve as a guideline for choice of treatment and investment strategies in hospitals. TRIAL REGISTRATION: ISRCTN44649165.

Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: a systematic review of literature.

BACKGROUND: Pelvic fractures can cause massive haemorrhage. Early stabilisation and compression of unstable fractures is thought to limit blood loss. Reposition of fracture parts and reduction of pelvic volume may provide haemorrhage control. Several non-invasive techniques for early stabilisation have been proposed, like the specifically designed pelvic circumferential compression devices (PCCD). The purpose of this systematic review was to investigate current evidence for the effectiveness and safety of non-invasive PCCDs. METHODS: To investigate current literature the search string: "pelvi* AND fract* AND (bind* OR t-pod OR tpod OR wrap OR circumferential compression OR sling OR sheet)" was entered into EMBASE, PubMed (Medline), PiCarta, WebofScience, Cochrane Online, UptoDate, CINAHL, and Scopus. All scientific publications published in indexed journals were included. RESULTS: The search resulted in 17 included articles, none of which were level I or II studies. One clinical cohort study (level III) and 1 case-control study (level IV) were found. These showed a significant reduction of pelvic volume after applying a PCCD, without an effect on outcome. Other included literature consisted of 4 case series (level V). Two biomechanical analysis studies of fractures in human cadavers showed pelvic stabilisation and effective volume reduction by PCCD, especially when applied around the greater trochanters. Finally, 7 case reports (level VI) and 3 expert opinions (level VII) were identified. These case reports suggested complications such as pressure sores and nerve palsy. CONCLUSION: PCCDs seem to be effective in early stabilisation of unstable pelvic fractures. However, prospective data concerning mortality and complications is lacking. Some complications, like pressure sores have been described.

Helicopter emergency medical services (HEMS): impact on on-scene times.

BACKGROUND: This study compared prehospital on-scene times (OSTs) for patients treated by nurse-staffed emergency medical services (EMS) with OST for patients treated by a combination of EMS and physician-staffed helicopter emergency medical services (HEMS). A secondary aim was to investigate the relationship between length of OST and mortality. METHODS: All trauma patients treated in the priority 1 emergency room of a Level I trauma center between January 2002 and 2004 were included in the study. To determine OST and outcome, hospital and prehospital data were entered into the trauma registry. OSTs for EMS and combined EMS/HEMS-treated patients were compared using linear regression analysis. Logistic regression analysis was used to compare mortality rates. RESULTS: The number of trauma patients included for analysis was 1,457. Of these, 1,197 received EMS assistance only, whereas 260 patients received additional care by an HEMS physician. HEMS patients had longer mean OSTs (35.4 vs. 24.6 minutes; p < 0.001) and higher Injury Severity Scores (24 vs. 9; p < 0.001). After correction for patient and trauma characteristics, like the Revised Trauma Score, age, Injury Severity Scores, daytime/night-time, and mechanism of trauma, the difference in OSTs between the groups was 9 minutes (p < 0.001). Logistic regression analyses showed a higher uncorrected chance of dying with increasing OST by 10 minutes (OR, 1.2; p < 0.001). This apparent effect of OST on mortality was explained by patient and trauma characteristics (adjusted OR, 1.0; p = 0.89). CONCLUSIONS: Combined EMS/HEMS assistance at an injury scene is associated with longer OST. When corrected for severity of injury and patient characteristics, no influence of longer OST on mortality could be demonstrated.

Physician-staffed HEMS dispatch in the Netherlands: Adequate deployment or minimal utilization?

INTRODUCTION: In the Netherlands, a physician-staffed helicopter emergency medical system (HEMS), called the Helicopter Mobile Medical Team (HMMT), provides prehospital care for severely injured patients in addition to ambulance services. This HMMT has proven to increase chances of survival and reduce morbidity. HMMT dispatch is performed following certain dispatch criteria. The goal of this study was to analyze actual dispatch rates and assess the protocol adherence of the emergency dispatchers in Rotterdam regarding HMMT dispatch. METHODS: All high priority ambulance runs between April 1 and July 1, 2003, were prospectively documented and cross-referenced to dispatch criteria. It was determined whether the emergency call warranted either immediate dispatch of the HMMT or a secondary dispatch after arrival of the first ambulance. When dispatch actually occurred, this was also documented. RESULTS: In The Studied Period A Total Of 5765 A1 Ambulance Runs During Daylight Were Documented. Of These, 1148 Runs Met Primary Dispatch Criteria And 38 Runs Met Secondary Dispatch Criteria. Actual Hmmt Dispatch Occured In 162/1186 (14%) Cases. CONCLUSIONS: HEMS dispatch rates and dispatch criteria adherence are low (14%). Better protocol adherence by emergency dispatchers could lead to a sevenfold increase of HMMT dispatches. The reasons for suboptimal protocol adherence remain unclear and persist, despite proven value of the HMMT in reducing patient mortality and morbidity.

Prehospital chest tube thoracostomy: effective treatment or additional trauma?

BACKGROUND: The use of prehospital chest tube thoracostomy (TT) remains controversial because of presumed increased complication risks. This study analyzed infectious complication rates for physician-performed prehospital and emergency department (ED) TT. METHODS: Over a 40-month period, all consecutive trauma patients with TT performed by the flight physician at the accident scene were compared with all patients with TT performed in the emergency department. Bacterial cultures, blood samples, and thoracic radiographs were reviewed for TT-related infections. RESULTS: Twenty-two patients received prehospital TTs and 101 patients received ED TTs. Infected hemithoraces related to TTs were found in 9% of those performed in the prehospital setting and 12% of ED-performed TTs (not significant). CONCLUSION: The prehospital chest tube thoracostomy is a safe and lifesaving intervention, providing added value to prehospital trauma care when performed by a qualified physician. The infection rate for prehospital TT does not differ from ED TT.