Improved chest wall trauma taxonomy: an interdisciplinary CWIS and ASER collaboration.

PURPOSE: Chest wall injury taxonomy and nomenclature are important components of chest wall injury classification and can be helpful in communicating between providers for treatment planning. Despite the common nature of these injuries, there remains a lack of consensus regarding injury description. The Chest Wall Injury Society (CWIS) developed a taxonomy among surgeons in the field; however, it lacked consensus and clarity in critical areas and collaboration with multidisciplinary partners. We believe an interdisciplinary collaboration between CWIS and American Society of Emergency Radiology (ASER) will improve existing chest wall injury nomenclature and help further research on this topic. METHODS: A collaboration between CWIS and ASER gathered feedback on the consensus recommendations. The workgroup held a series of meetings reviewing each consensus statement, refining the terminology, and contributing additional clarifications from a multidisciplinary lens. RESULTS: After identifying incomplete definitions in the CWIS survey, the workgroup expanded on and clarified the language proposed by the survey. More precise definitions related to rib and costal cartilage fracture quality and location were developed. Proposed changes include more accurate characterization of rib fracture displacement and consistent description of costal cartilage fractures. CONCLUSIONS: The 2019 consensus survey from CWIS provides a framework to discuss chest wall injuries, but several concepts remained unclear. Creating a universally accepted taxonomy and nomenclature, utilizing the CWIS survey and this article as a scaffolding, may help providers communicate the severity of chest wall injury accurately, allow for better operative planning, and provide a common language for researchers in the future.

An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers study (CWIS-CC2).

BACKGROUND: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. METHODS: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded. RESULTS: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF. CONCLUSION: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury.

PURPOSE: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients. METHODS: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern. RESULTS: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034). CONCLUSION: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

Surgical stabilization of rib fractures combined with intercostal nerve cryoablation proves to be more cost effective by reducing hospital length of stay and narcotics.

BACKGROUND: Intercostal nerve cryoablation (INCA) coupled with surgical stabilization of rib fractures (SSRF) has been shown to reduce post-operative pain scores but at what monetary cost. We hypothesize that in-hospital outcomes improve with the addition of INCA to SSRF and potential increased hospital charges are justified by patient benefits. METHODS: Multi-institutional, retrospective review of patients undergoing SSRF with and without INCA over an 8-year period. Institutions involved were Level II or higher trauma centers. Basic demographics were obtained. Patients were included if SSRF was performed during the index hospitalization. Primary outcomes included total hospital length of stay (HLOS) and HLOS after SSRF, total hospital charges (HC), HC the day of surgery and HC after surgery. Secondary outcome included total narcotic consumption in morphine milliequivalents (MME) after SSRF. Mann-Whitney U test was used for analysis. Statistical significance p < 0.05. RESULTS: 136 patients analyzed; 92 underwent SSRF only and 44 underwent SSRF with INCA. Demographics were similar between groups. Number of ribs stabilized was comparable; 4.78 ± 1.64 SSRF only and 4.73 ± 1.66 SSRF with INCA (p = 0.463). Median ISS [16 (IQR 11.5-16) SSRF only and 14 (IQR 9-18.75) SSRF with INCA (p = 0.463)] was not statistically different. The INCA group showed a decrease in the median total HLOS, 9 versus 10 days (U = 1517.5, p = 0.026) and HLOS after SSRF, 4 versus 6 days (U = 1217.5, p < 0.001). HC the day of surgery were higher for the INCA group, $93,932 versus $71,143 (U = 1106, p < 0.001). However, total HC were similar between groups and total HC after SSRF was significantly less for the INCA group, $10,556 versus $20,269 (U = 1327, p = 0.001). Total median narcotic use after SSRF was significantly less for the INCA group, 88.6 vs 113.7 MME (U = 1544.5, p = 0.026). CONCLUSION: SSRF with INCA is safe and does not increase overall HC with the added benefit of decreased HLOS post-operatively and decreased narcotic consumption.

Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI).

BACKGROUND: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI. METHODS: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI. RESULTS: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034). CONCLUSION: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI. LEVEL OF EVIDENCE: Therapeutic, level IV.

Esophageal perforation in children: a review of one institution's experience.

BACKGROUND: The current approach to esophageal perforation treatment in children has shifted towards conservative management. However, the consensus of what constitutes conservative management is unclear, with various therapies and protocols described, including the need for various decompression and drainage procedures. Our institution utilizes conservative management with minimal intervention guided by the patient's clinical course. The purpose of this study is to report our management and add to the growing evidence for conservative management of esophageal perforation in children. METHODS: We performed a retrospective chart review of all patients with an ICD-9 diagnosis of esophageal perforation from January 1995 to July 2009. Patients with postoperative anastomotic leaks with drains in place were excluded, although patients with anastomotic leaks that were not controlled by drains were included. Data collected included patient demographics, etiology, diagnosis, treatment, complications, and outcome. RESULTS: Eight patients were identified who met inclusion criteria. Mean age was 28 mo (1 d-10 y), and the average time from causative event to diagnosis was 1.4 d (0-2 d). The etiology for esophageal perforation included esophagoscopy with dilation (n = 4), button battery ingestion (n = 1), coin ingestion (n = 1), nasogastric tube placement (n = 1), and leak after stricture resection (n = 1). All the patients were treated conservatively without primary surgery or thoracic drainage, and the mean time to perforation healing was 10.2 d (1-24 d). The average length of antibiotic therapy was 10 d (0-26 d). Enteral nutrition was utilized in five patients, and total parenteral nutrition (TPN) was utilized in five patients. No patient developed a new-onset esophageal stricture. CONCLUSION: Conservative management, guided by the patient's clinical course, with antibiotics and nutritional support is a safe and effective treatment for esophageal perforations in children.

Effect of Kasai procedure on hepatic outcome in Alagille syndrome.

OBJECTIVES: Alagille syndrome (AGS) frequently presents with neonatal jaundice and can mimic other causes of high gamma-glutamyl transpeptidase (GGT) cholestasis, most notably biliary atresia. As a result infants with AGS may undergo intraoperative cholangiogram and even Kasai procedure. The aim of the study was to assess the hepatic outcomes of children with AGS who underwent the Kasai procedure. PATIENTS AND METHODS: A retrospective review of the AGS clinical database at the Children's Hospital of Philadelphia was performed to identify clinically defined patients with AGS who underwent a Kasai. A cohort of Alagille control subjects was selected with equivalent symptoms of neonatal jaundice and matched for age and presence of cardiac anomaly. JAGGED1-mutation analysis was performed on available samples. Clinical courses were reviewed. Fisher exact and t tests were used for analysis. RESULTS: Of the 430 patients with AGS, 19 underwent a Kasai procedure (K). The control cohort (C) consisted of 36 patients. Total bilirubin measured between 6 and 10 weeks of age in each cohort was equivalent (K: 9.6 mg/dL, C: 8.7 mg/dL); GGT levels were higher in the control group (K:493.4 U/L, C:574.4 U/L). Of note, the Kasai cohort had a significantly larger number of liver transplants (K: 9 [47.3%], C: 5 [13.9%], P = 0.01) and sustained higher mortality (K: 6 [31.6%], C: 1 [2.8%], P = 0.005). There was no genotype-phenotype correlation between the mutations identified and patients who underwent Kasai. CONCLUSIONS: These data suggest that the Kasai procedure, although appropriate for children with biliary atresia, does not benefit children with AGS and actually appears to worsen outcome. The current data suggest that the Kasai is not a marker for underlying severe liver disease, but the procedure itself may have a detrimental effect on outcome. An appropriate medical evaluation and particular consideration of AGS is essential before surgical referral in infants with high GGT cholestasis.

Mild traumatic brain injury in the pediatric population: the role of the pediatrician in routine follow-up.

BACKGROUND: Traumatic brain injury is common in children. Fortunately, most patients suffer mild traumatic brain injury (MTBI). Appropriate guidelines for follow-up care are not well established. We sought to determine practice experience and preferences of general pediatricians related to follow-up care of MTBI. METHODS: Members of the American Academy of Pediatrics Council of Community Pediatrics and general pediatricians in the Pennsylvania Chapter of the American Academy of Pediatrics participated in a web-based survey regarding practice setting, level of comfort caring for patients with MTBI, and referral patterns for such patients. RESULTS: A total of 298 pediatricians responded. An urban or suburban practice setting was reported by 83.3% with a wide distribution in practice experience (0-10 years 40.5%, 11-20 years 24.5%, >21 years 35%). Most respondents (54.5%) had cared for at least 2 to 5 patients with MTBI in the past 6 months but only 8% had seen >10 patients. Fifty-nine percent had not participated in continuing medical education activities related to MTBI and 62.2% did not use neurocognitive tests. The majority (89%) thought that they were the appropriate provider for follow-up; this declined to 61.2% for patients with loss of consciousness and only 5.4% if patients had persistent symptoms. Neurologists (75%) were the consultant of choice for referral. Increased practice experience was associated with an increased comfort in determining return to play status. CONCLUSION: In this survey, pediatricians thought that they were the most appropriate clinicians to follow-up patients with MTBI. However, most accepted this responsibility without the benefit of specific continuing medical education or using neurocognitive tests. Ensuring the availability of appropriate resources for pediatricians to care for these patients is important.

Sternal wound reconstruction: management in different cardiac populations.

Poststernotomy mediastinitis is a feared complication for patients undergoing cardiac surgery associated with high rates of morbidity and mortality. Approximately 15% of patients will ultimately be readmitted for a recurrent sternal wound infection. The objective of this study is to review a large single surgeon experience with sternal wound patients managed with a variety of soft tissue flaps to assess mitigating factors, involved organisms, and treatment protocols as related to specific cardiac populations. Records for 136 sternal reconstruction patients treated from January 2000 to July 2007 were evaluated. Patients underwent a variety of cardiac surgeries including coronary artery bypass grafting (CABG), valve replacement, aortic reconstruction, heart transplantation, lung transplantation, and combinations of these procedures. A total of 39.2% of patients developed a sternal wound during the same admission as their cardiac surgery, at an average of 16.1 days. This rate was only 6% for CABG-only patients and rose to nearly 50% in heart transplant and CABG + valve patients. A total of 78.6% of heart transplant patients with a sternal wound had a history of ventricular assist device and 41% of all patients had at least 1 previous sternotomy. Thirteen patients (9.6%) had 1 or more recurrent infections requiring surgery; 50% occurring in transplant patients, most of whom had diabetes and/or renal insufficiency. The most common presenting symptom was drainage (n = 75, 55.6%) or wound dehiscence (n = 22, 16.3%). Twenty-five different organisms were identified; 26 patients (18.5%) had multiple organisms. Staphylococcus species were most common. Plastic surgery intervention occurred on average 109.2 days after cardiac surgery. CABG and CABG + valve patients most frequently received right pectoralis muscle turnover flaps or left pectoralis muscle advancement flaps. Ten heart transplant patients (37.0%) underwent omental flaps. The 30-day perioperative mortality rate was 13 patients (9.6%).

Emergency department length of stay: a major risk factor for pneumonia in intubated blunt trauma patients.

BACKGROUND: Pneumonia occurs commonly in intubated patients and is morbid and occasionally mortal. Pneumonia prevention strategies have been successful in the intensive care unit and are favorably regarded, cost effective, and efficacious. Trauma patients are often intubated emergently in the prehospital or emergency department (ED) setting. Nationwide, hospital crowding has resulted in prolonged ED length of stay (LOS). We sought to study the association between prolonged ED LOS and rates of pneumonia. METHODS: This was a 2-year retrospective case-control study of pneumonia risk among blunt trauma patients presenting to an urban Level I trauma center who were emergently intubated. The trauma registry was queried for demographic and clinical information. All patients who were intubated prehospital or in the ED and developed pneumonia were identified as cases. A group of matched controls with equivalent age, injury severity score, abbreviated injury score (AIS) chest, and AIS head who did not develop pneumonia were identified. A comparison of ED LOS between the two groups was assessed using conditional logistic regression. RESULTS: We identified 509 emergently intubated blunt trauma patients. Of these, 33 developed pneumonia and could be matched with comparable controls. The case subjects had a mean age of 44.6 (+/-24.3), a mean injury severity score of 32.7 (+/- 9.4), a mean chest AIS of 1.5 (+/-1.6), and a mean head AIS of 4.4 (+/-1.2). The ED LOS for the cases was significantly longer than that for the controls (281.3 minutes vs. 214.0 minutes, p < 0.05). Each hour increased the risk of developing pneumonia by approximately 20%. CONCLUSIONS: In blunt trauma patients who are emergently intubated, increased ED LOS is an independent risk factor for pneumonia. Ventilator associated pneumonia interventions, successful in the intensive care unit, should be implemented early in the hospital course, and efforts should be made to minimize hospital crowding and ED LOS.

Use of laparoscopic cholecystectomy for biliary dyskinesia in the child.

BACKGROUND: Biliary dyskinesia (BD) is a consideration as a cause of chronic abdominal pain in the pediatric population. We sought to correlate the results of cholecystokinin-diisopropyl iminodiacetic acid (CCK-DISIDA) scanning, the basis for diagnosis of BD, with outcome after laparoscopic cholecystectomy. METHODS: A retrospective review was performed of all patients who underwent a laparoscopic cholecystectomy from May 2000 through March 2007. The diagnosis of BD was based on CCK-DISIDA scan demonstrating a gallbladder ejection fraction (GBEF) of less than 35% and/or reproduction of pain on CCK administration or no filling of the gall bladder with a normal ultrasound examination. Hospital, General Surgery office, and Gastroenterology Office charts were reviewed for demographic and management data points. We used chi(2) and Mann-Whitney tests for statistical analysis. RESULTS: For the period of review, 430 patients underwent a laparoscopic cholecystectomy including 75 patients with a preoperative diagnosis of BD. The mean age of the BD population was 14 (range, 9-19) years. Female to male ratio was 2.4:1. The mean body mass index was 24.4 kg/m(2). On average, patients had abdominal symptoms for 15.5 (range, 0.25-72) months. Each patient underwent nearly 2.5 studies (computed tomography, ultrasound, esophagogastroduodenoscopy, or upper gastrointestinal series) before diagnosis by CCK-DISIDA. The mean GBEF was 17.4%. When commented on (n = 41), pain on CCK administration was noted in 25 (61%) patients. Pathology revealed chronic cholecystitis in 44%. After laparoscopic cholecystectomy, 58 (77.33%) patients reported resolution of their abdominal pain (mean follow-up 4 months). Of the 17 patients without improvement, 7 were later diagnosed with other underlying pathology (Crohn's, hiatal hernia, cyclic vomiting). There was no difference in GBEF, age, histopathology, or sex between the two groups. There were no complications. CONCLUSION: Laparoscopic cholecystectomy is a safe and effective treatment for the majority of children diagnosed with BD. Although CCK-DISIDA was used to identify biliary dysfunction, it did not correlate with outcome.

Complex vascular reconstruction of abdominal aorta and its branches in the pediatric population.

BACKGROUND: Subdiaphragmatic aortic diseases in children are rare and form a heterogeneous group. The pediatric patient presents unique challenges because of their size, concerns about proper timing and conduit for repair, and anticipating expected growth. METHODS: We performed a retrospective review of operations involving the abdominal aorta and called branches in children between January 2003 and April 2007, focusing on the details of preoperative evaluation, operative technique, and outcomes. The pertinent literature is reviewed. RESULTS: Twenty-two children (age, 2 days to 17 years) were included. Mean follow-up was 28 months. Aneurysms were seen in 5 children; the remainder had stenotic disease. Aneurysms were typically asymptomatic and diagnosed incidentally, whereas stenotic lesions most commonly presented with hypertension (HTN). Fourteen complex vascular repairs were performed. All of the children with aneurysms underwent prompt surgery. The children with stenoses had operations for poorly controlled HTN, claudication, and/or mesenteric ischemia. Most patients with stenotic disease were treated medically for HTN and were followed closely while awaiting optimal size and availability of autogenous conduit for reconstruction. Cryopreserved allograft was used in 3 of the aneurysm operations. Dacron grafts were used to repair 5 aortic stenotic lesions. Renal and mesenteric revascularizations were performed with saphenous vein grafts. Pediatric, general, and transplant surgeons and nephrologic and cardiologic teams were integral to evaluation and management. No major operative complications occurred. CONCLUSION: Proper management of pediatric aortic vascular disease requires a multidisciplinary approach. It is best to use autologous grafts whenever possible. Children with stenotic disease should be treated medically for hypertension until they are large enough for an autologous graft reconstruction. Children with aneurysmal disease are at risk for embolism and thrombosis and therefore usually treated immediately using artificial graft material, if necessary.